Provider Demographics
NPI:1861474058
Name:BURRESS, KENT REYNOLDS (DPM)
Entity Type:Individual
Prefix:
First Name:KENT
Middle Name:REYNOLDS
Last Name:BURRESS
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1819 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47714
Mailing Address - Country:US
Mailing Address - Phone:812-477-0200
Mailing Address - Fax:812-477-1267
Practice Address - Street 1:1819 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47714
Practice Address - Country:US
Practice Address - Phone:812-457-7020
Practice Address - Fax:812-477-0200
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-15
Last Update Date:2008-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN0700515213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100246800AMedicaid
IN846950Medicare PIN
IN100246800AMedicaid