Provider Demographics
NPI:1922359454
Name:BURNETT, DERRICK TROY
Entity Type:Individual
Prefix:MR
First Name:DERRICK
Middle Name:TROY
Last Name:BURNETT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8355 CRESTWAY DR APT 620
Mailing Address - Street 2:
Mailing Address - City:CONVERSE
Mailing Address - State:TX
Mailing Address - Zip Code:78109-3613
Mailing Address - Country:US
Mailing Address - Phone:210-429-4536
Mailing Address - Fax:
Practice Address - Street 1:8355 CRESTWAY DR APT 620
Practice Address - Street 2:
Practice Address - City:CONVERSE
Practice Address - State:TX
Practice Address - Zip Code:78109-3613
Practice Address - Country:US
Practice Address - Phone:210-429-4536
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-24
Last Update Date:2012-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist