Provider Demographics
NPI:1962456327
Name:BURGETT, PAUL MARCUS (MD)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:MARCUS
Last Name:BURGETT
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 2758
Mailing Address - Street 2:
Mailing Address - City:WATERLOO
Mailing Address - State:IA
Mailing Address - Zip Code:50704-2758
Mailing Address - Country:US
Mailing Address - Phone:319-833-5907
Mailing Address - Fax:319-833-5908
Practice Address - Street 1:1753 W RIDGEWAY AVE
Practice Address - Street 2:STE 107
Practice Address - City:WATERLOO
Practice Address - State:IA
Practice Address - Zip Code:50701-4588
Practice Address - Country:US
Practice Address - Phone:319-833-5907
Practice Address - Fax:319-833-5908
Is Sole Proprietor?:No
Enumeration Date:2006-05-20
Last Update Date:2022-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA32454208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA45674OtherWELLMARK INS PLAN
IA421417307B8OtherJOHN DEERE HEALTH CARE
IA0177436Medicaid
G73543Medicare UPIN
IA45674Medicare ID - Type Unspecified