Provider Demographics
NPI:1902842933
Name:BURKHARDT, JACQUELINE A (OD)
Entity Type:Individual
Prefix:MS
First Name:JACQUELINE
Middle Name:A
Last Name:BURKHARDT
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:331 N YORK RD
Mailing Address - Street 2:
Mailing Address - City:HATBORO
Mailing Address - State:PA
Mailing Address - Zip Code:19040-2033
Mailing Address - Country:US
Mailing Address - Phone:215-672-4300
Mailing Address - Fax:215-672-9524
Practice Address - Street 1:331 N YORK RD
Practice Address - Street 2:
Practice Address - City:HATBORO
Practice Address - State:PA
Practice Address - Zip Code:19040-2033
Practice Address - Country:US
Practice Address - Phone:215-672-4300
Practice Address - Fax:215-672-9524
Is Sole Proprietor?:No
Enumeration Date:2006-06-20
Last Update Date:2015-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC3874152W00000X
PAOEG003007152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL620951300Medicaid
V01571Medicare UPIN
FLU3394WMedicare PIN