Provider Demographics
NPI:1295895985
Name:BURK, THOMAS WARD (OD)
Entity type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:WARD
Last Name:BURK
Suffix:
Gender:M
Credentials:OD
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 999
Mailing Address - Street 2:
Mailing Address - City:YUBA CITY
Mailing Address - State:CA
Mailing Address - Zip Code:95992-0999
Mailing Address - Country:US
Mailing Address - Phone:530-671-1740
Mailing Address - Fax:530-671-1380
Practice Address - Street 1:1050 LIVE OAK BLVD
Practice Address - Street 2:
Practice Address - City:YUBA CITY
Practice Address - State:CA
Practice Address - Zip Code:95991-3415
Practice Address - Country:US
Practice Address - Phone:530-671-1740
Practice Address - Fax:530-671-1380
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT 4970 TPA152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0049700Medicaid
CAT09837Medicare UPIN