Provider Demographics
NPI:1326009200
Name:BURNETT, KEITH R (MD)
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:R
Last Name:BURNETT
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 91689
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90809-1689
Mailing Address - Country:US
Mailing Address - Phone:949-784-2303
Mailing Address - Fax:
Practice Address - Street 1:4200 E PCH
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90804-2107
Practice Address - Country:US
Practice Address - Phone:949-784-2303
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-30
Last Update Date:2015-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG409592085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA48412Medicare UPIN
CAWG40959BMedicare PIN
CAWG40959EMedicare PIN
CAWG40959DMedicare PIN
CAWG40959CMedicare PIN