Provider Demographics
NPI:1457533473
Name:BURGESS, ROXANNE L (DPM)
Entity Type:Individual
Prefix:DR
First Name:ROXANNE
Middle Name:L
Last Name:BURGESS
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11030 S TRYON ST
Mailing Address - Street 2:STE 308
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28273-6545
Mailing Address - Country:US
Mailing Address - Phone:704-504-1004
Mailing Address - Fax:704-504-0007
Practice Address - Street 1:11030 S TRYON ST
Practice Address - Street 2:STE 308
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28273-6545
Practice Address - Country:US
Practice Address - Phone:704-504-1004
Practice Address - Fax:704-504-0007
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-30
Last Update Date:2021-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCNC461213ES0103X, 213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5564660001OtherCIGNA GOVERNMENT SERVICES
NC89081AVMedicaid
SCNPD461Medicaid
NC081AVOtherBCBS
NC5564660001Medicare NSC
NC081AVOtherBCBS
SCNPD461Medicaid