Provider Demographics
NPI:1972665818
Name:BURGESS, ROBERT LEO (OPTICIAN)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:LEO
Last Name:BURGESS
Suffix:
Gender:M
Credentials:OPTICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 TOURO ST
Mailing Address - Street 2:
Mailing Address - City:NEWPORT
Mailing Address - State:RI
Mailing Address - Zip Code:02840-2912
Mailing Address - Country:US
Mailing Address - Phone:401-846-0101
Mailing Address - Fax:401-846-6161
Practice Address - Street 1:15 TOURO ST
Practice Address - Street 2:
Practice Address - City:NEWPORT
Practice Address - State:RI
Practice Address - Zip Code:02840-2912
Practice Address - Country:US
Practice Address - Phone:401-846-0101
Practice Address - Fax:401-846-6161
Is Sole Proprietor?:No
Enumeration Date:2006-12-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIOP 00169156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI412086OtherBLUE CHIP
RI0000029104-0OtherBLUE SHIELD