Provider Demographics
NPI:1134446263
Name:BURCKARDT, KENNETH ALAN (MD)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:ALAN
Last Name:BURCKARDT
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 843603
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-3603
Mailing Address - Country:US
Mailing Address - Phone:972-233-1999
Mailing Address - Fax:972-233-3666
Practice Address - Street 1:6435 W JEFFERSON BLVD # 434
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-6203
Practice Address - Country:US
Practice Address - Phone:260-436-7875
Practice Address - Fax:260-432-9812
Is Sole Proprietor?:No
Enumeration Date:2010-04-29
Last Update Date:2024-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01074085A207L00000X
KY55448207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100458340Medicaid
IN201250880Medicaid