Provider Demographics
NPI:1861479412
Name:BURKHARDT, GARY JOHN (OD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:JOHN
Last Name:BURKHARDT
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CHILTON
Mailing Address - State:WI
Mailing Address - Zip Code:53014-1323
Mailing Address - Country:US
Mailing Address - Phone:920-849-4291
Mailing Address - Fax:920-849-4292
Practice Address - Street 1:19 W MAIN ST
Practice Address - Street 2:
Practice Address - City:CHILTON
Practice Address - State:WI
Practice Address - Zip Code:53014-1323
Practice Address - Country:US
Practice Address - Phone:920-849-4291
Practice Address - Fax:920-849-4292
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-26
Last Update Date:2013-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1989035152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38588600Medicaid
WI38588600Medicaid
WI0632280001Medicare NSC
WI87992Medicare ID - Type Unspecified