Provider Demographics
NPI:1497913040
Name:BURCHAM C. FUQUA, MD, PA
Entity type:Organization
Organization Name:BURCHAM C. FUQUA, MD, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BURCHAM
Authorized Official - Middle Name:COOPER
Authorized Official - Last Name:FUQUA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:361-991-7039
Mailing Address - Street 1:5826 ESPLANADE DR
Mailing Address - Street 2:SUITE 303
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78414-4173
Mailing Address - Country:US
Mailing Address - Phone:361-991-7039
Mailing Address - Fax:361-994-1941
Practice Address - Street 1:5826 ESPLANADE DR
Practice Address - Street 2:SUITE 303
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78414-4173
Practice Address - Country:US
Practice Address - Phone:361-991-7039
Practice Address - Fax:361-994-1941
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-30
Last Update Date:2010-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF9456207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
00102ZMedicare PIN