Provider Demographics
NPI:1891706354
Name:BURKART, KIETH J (OD)
Entity Type:Individual
Prefix:DR
First Name:KIETH
Middle Name:J
Last Name:BURKART
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:PO BOX 2226
Mailing Address - Street 2:
Mailing Address - City:LAKE ARROWHEAD
Mailing Address - State:CA
Mailing Address - Zip Code:92352-2226
Mailing Address - Country:US
Mailing Address - Phone:909-337-4310
Mailing Address - Fax:
Practice Address - Street 1:29099 HOSPITAL RD
Practice Address - Street 2:SUITE 205
Practice Address - City:LAKE ARROWHEAD
Practice Address - State:CA
Practice Address - Zip Code:92352-2226
Practice Address - Country:US
Practice Address - Phone:909-337-4310
Practice Address - Fax:909-336-5937
Is Sole Proprietor?:No
Enumeration Date:2006-08-10
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA5639152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0056391Medicare PIN
CA6108320001Medicare NSC
CAT10064Medicare UPIN