Provider Demographics
NPI:1942288618
Name:BURDETTE, JOHN (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:
Last Name:BURDETTE
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 1:924 N HOWE ST
Mailing Address - Street 2:
Mailing Address - City:SOUTHPORT
Mailing Address - State:NC
Mailing Address - Zip Code:28461-3099
Mailing Address - Country:US
Mailing Address - Phone:304-610-2517
Mailing Address - Fax:
Practice Address - Street 1:924 N HOWE ST
Practice Address - Street 2:
Practice Address - City:SOUTHPORT
Practice Address - State:NC
Practice Address - Zip Code:28461-3099
Practice Address - Country:US
Practice Address - Phone:910-457-4739
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-04
Last Update Date:2024-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV14099208D00000X
NC3801208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1053225OtherWV DWC
WV001718056OtherWV BCBS
NC0051084000Medicaid
WV0051084000Medicaid
WVBU4037075Medicare PIN
WV110215150Medicare PIN
WV110237553Medicare PIN
WV0051084000Medicaid
WVBU4037072Medicare PIN
WVD17662Medicare UPIN