Provider Demographics
NPI:1821752411
Name:BURTON, JUVAN LAMONT SR
Entity Type:Individual
Prefix:MR
First Name:JUVAN
Middle Name:LAMONT
Last Name:BURTON
Suffix:SR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19722 MESQUITE BRANCH CT
Mailing Address - Street 2:
Mailing Address - City:SPRING
Mailing Address - State:TX
Mailing Address - Zip Code:77388-5310
Mailing Address - Country:US
Mailing Address - Phone:414-779-7091
Mailing Address - Fax:
Practice Address - Street 1:19722 MESQUITE BRANCH CT
Practice Address - Street 2:
Practice Address - City:SPRING
Practice Address - State:TX
Practice Address - Zip Code:77388-5310
Practice Address - Country:US
Practice Address - Phone:414-779-7091
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-28
Last Update Date:2021-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172A00000XOther Service ProvidersDriverGroup - Single Specialty