Provider Demographics
NPI:1922039643
Name:BURNISON, THOMAS B (MD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:B
Last Name:BURNISON
Suffix:
Gender:M
Credentials:MD
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 160
Mailing Address - Street 2:
Mailing Address - City:SHIPROCK
Mailing Address - State:NM
Mailing Address - Zip Code:87420-0160
Mailing Address - Country:US
Mailing Address - Phone:505-368-6001
Mailing Address - Fax:
Practice Address - Street 1:US HWY 491 NORTH
Practice Address - Street 2:
Practice Address - City:SHIPROCK
Practice Address - State:NM
Practice Address - Zip Code:87420
Practice Address - Country:US
Practice Address - Phone:505-368-6001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2019-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.0043984207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ163075Medicaid
NM56328257Medicaid
CO84873060Medicaid
8HF664Medicare PIN
NM56328257Medicaid
320059Medicare Oscar/Certification