Provider Demographics
NPI:1649332727
Name:BURGHART, CURTIS DEAN (OD)
Entity type:Individual
Prefix:DR
First Name:CURTIS
Middle Name:DEAN
Last Name:BURGHART
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1203 S GOLD ST
Mailing Address - Street 2:
Mailing Address - City:CENTRALIA
Mailing Address - State:WA
Mailing Address - Zip Code:98531-3715
Mailing Address - Country:US
Mailing Address - Phone:360-736-4203
Mailing Address - Fax:360-736-7059
Practice Address - Street 1:1203 S GOLD ST
Practice Address - Street 2:
Practice Address - City:CENTRALIA
Practice Address - State:WA
Practice Address - Zip Code:98531-3715
Practice Address - Country:US
Practice Address - Phone:360-736-4203
Practice Address - Fax:360-736-7059
Is Sole Proprietor?:No
Enumeration Date:2006-12-14
Last Update Date:2014-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA1838152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2013225Medicaid
WAT12471Medicare UPIN
WA4710560001Medicare NSC
WAAB35380Medicare PIN
WAAB35379Medicare ID - Type UnspecifiedGRP#