Provider Demographics
NPI:1649385378
Name:BURGETT, DAVID R (OD)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:R
Last Name:BURGETT
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 1:6451 N TIERRA DE LAS CATALINAS
Mailing Address - Street 2:APT 64
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85718-2162
Mailing Address - Country:US
Mailing Address - Phone:602-517-5059
Mailing Address - Fax:
Practice Address - Street 1:16129 W MORNING GLORY ST
Practice Address - Street 2:
Practice Address - City:GOODYEAR
Practice Address - State:AZ
Practice Address - Zip Code:85338-6800
Practice Address - Country:US
Practice Address - Phone:602-644-1008
Practice Address - Fax:602-644-1008
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-21
Last Update Date:2018-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1290152W00000X
CAOPT12244152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWOP12244AMedicare ID - Type Unspecified
CAU95452Medicare UPIN