Provider Demographics
NPI:1295729481
Name:BURNHAM, JEFFREY MARK (MD)
Entity type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:MARK
Last Name:BURNHAM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:12916 MORGAN MEADOW AVENUE
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70818
Mailing Address - Country:US
Mailing Address - Phone:225-938-9287
Mailing Address - Fax:225-237-1786
Practice Address - Street 1:10310 THE GROVE BLVD STE 100
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70836-6455
Practice Address - Country:US
Practice Address - Phone:225-761-5200
Practice Address - Fax:225-761-5702
Is Sole Proprietor?:No
Enumeration Date:2005-09-02
Last Update Date:2021-03-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
LA017109207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1357502Medicaid
LA080179868OtherRAILROAD MEDICARE
LA51608CD43Medicare PIN
B63211Medicare UPIN