Provider Demographics
NPI:1871852236
Name:BURBANK, FRED HURD (MD)
Entity Type:Individual
Prefix:DR
First Name:FRED
Middle Name:HURD
Last Name:BURBANK
Suffix:
Gender:M
Credentials:MD
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Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:24040 CAMINO DEL AVION
Mailing Address - Street 2:A326
Mailing Address - City:DANA POINT
Mailing Address - State:CA
Mailing Address - Zip Code:92629-4005
Mailing Address - Country:US
Mailing Address - Phone:949-496-0026
Mailing Address - Fax:949-496-3247
Practice Address - Street 1:24040 CAMINO DEL AVION
Practice Address - Street 2:A326
Practice Address - City:DANA POINT
Practice Address - State:CA
Practice Address - Zip Code:92629-4005
Practice Address - Country:US
Practice Address - Phone:949-496-0026
Practice Address - Fax:949-496-3247
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-04
Last Update Date:2012-05-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG167352084P0800X, 2085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA39885Medicare UPIN