Provider Demographics
NPI:1972587566
Name:BURKETT, MARK A (DO)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:A
Last Name:BURKETT
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:1234 E DUPONT RD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46825-1545
Mailing Address - Country:US
Mailing Address - Phone:260-373-9700
Mailing Address - Fax:260-373-9740
Practice Address - Street 1:1270 E STATE ROAD 205
Practice Address - Street 2:SUITE 150
Practice Address - City:COLUMBIA CITY
Practice Address - State:IN
Practice Address - Zip Code:46725-9499
Practice Address - Country:US
Practice Address - Phone:260-248-9890
Practice Address - Fax:260-248-9895
Is Sole Proprietor?:No
Enumeration Date:2005-12-06
Last Update Date:2013-03-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IN02002438A207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
00000968827 05OtherUNITED HEALTHCARE
IN3937240004OtherMEDICARE DMEPOS
IN12730OtherPHYSICIANS HEALTH PLAN
4270901OtherAETNA
IN000000210720OtherANTHEM
IN200367950Medicaid
IN110231565OtherRAILROAD MEDICARE
IN069860LLLMedicare PIN
00000968827 05OtherUNITED HEALTHCARE
IN12730OtherPHYSICIANS HEALTH PLAN