Provider Demographics
NPI:1902829716
Name:BURGHARDT, THOMAS MATTHEW (DPM)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:MATTHEW
Last Name:BURGHARDT
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 1:1610 BISHOP RD SW STE 101
Mailing Address - Street 2:
Mailing Address - City:TUMWATER
Mailing Address - State:WA
Mailing Address - Zip Code:98512-7303
Mailing Address - Country:US
Mailing Address - Phone:360-338-0004
Mailing Address - Fax:360-753-4861
Practice Address - Street 1:3929 BRIDGEPORT WAY W STE 308
Practice Address - Street 2:
Practice Address - City:UNIVERSITY PLACE
Practice Address - State:WA
Practice Address - Zip Code:98466-4455
Practice Address - Country:US
Practice Address - Phone:253-272-2999
Practice Address - Fax:253-272-4699
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2021-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPO 00000546213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7122997Medicaid
WA1094770Medicaid
WA1094770Medicaid
WA7122997Medicaid
WAAB33649Medicare PIN