Provider Demographics
NPI:1396727392
Name:FUQUA, BURCHAM COOPER JR (MD)
Entity type:Individual
Prefix:DR
First Name:BURCHAM
Middle Name:COOPER
Last Name:FUQUA
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:3434 SARATOGA BLVD
Mailing Address - Street 2:
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78415-5822
Mailing Address - Country:US
Mailing Address - Phone:361-985-9355
Mailing Address - Fax:361-992-3458
Practice Address - Street 1:3434 SARATOGA BLVD
Practice Address - Street 2:
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78415-5822
Practice Address - Country:US
Practice Address - Phone:361-985-9355
Practice Address - Fax:361-992-3458
Is Sole Proprietor?:No
Enumeration Date:2005-11-16
Last Update Date:2016-07-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXF9456207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX122175602Medicaid
TXTXB149313OtherWELLMED PTAN
TX122175606Medicaid
C15825Medicare UPIN
TX122175606Medicaid