Provider Demographics
NPI:1669730313
Name:BURTON, MATTHEW RYAN (MD)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:RYAN
Last Name:BURTON
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 1:4150 NELSON RD STE C10
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70605-4169
Mailing Address - Country:US
Mailing Address - Phone:337-240-7280
Mailing Address - Fax:337-240-7288
Practice Address - Street 1:4150 NELSON RD STE C10
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70605-4169
Practice Address - Country:US
Practice Address - Phone:
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-01
Last Update Date:2022-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA311945207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2510363Medicaid
LA311945OtherSTATE LICENSE