Provider Demographics
NPI:1639240765
Name:BURGESS, LATASHA (MD)
Entity type:Individual
Prefix:DR
First Name:LATASHA
Middle Name:
Last Name:BURGESS
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 E CHEVES ST STE 400
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:SC
Mailing Address - Zip Code:29506-2649
Mailing Address - Country:US
Mailing Address - Phone:843-777-7341
Mailing Address - Fax:843-777-7345
Practice Address - Street 1:800 E CHEVES ST STE 400
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:SC
Practice Address - Zip Code:29506-2649
Practice Address - Country:US
Practice Address - Phone:843-777-7341
Practice Address - Fax:843-777-7345
Is Sole Proprietor?:No
Enumeration Date:2006-11-12
Last Update Date:2025-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC92875207QA0505X
GA049877207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000915846DMedicaid
GA000915846DMedicaid
GAH42643Medicare UPIN