Provider Demographics
NPI:1669431367
Name:BURSZTYN, ENRIQUE M (MD)
Entity type:Individual
Prefix:
First Name:ENRIQUE
Middle Name:M
Last Name:BURSZTYN
Suffix:
Gender:M
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:PO BOX 3212
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46206-3212
Mailing Address - Country:US
Mailing Address - Phone:800-841-4236
Mailing Address - Fax:
Practice Address - Street 1:301 E MIEL DE LUNA AVE
Practice Address - Street 2:
Practice Address - City:TUCUMCARI
Practice Address - State:NM
Practice Address - Zip Code:88401-3810
Practice Address - Country:US
Practice Address - Phone:800-841-4236
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-21
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01063267A2085N0700X, 2085R0202X
NY145707-12085R0202X
NMMD2016-06352085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYA64774Medicare UPIN
IN443010OMedicare PIN
IN281450MMedicare PIN