Provider Demographics
NPI:1740902675
Name:P. ROMAN BURK DPM PC
Entity type:Organization
Organization Name:P. ROMAN BURK DPM PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:P.
Authorized Official - Middle Name:ROMAN
Authorized Official - Last Name:BURK
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:208-855-0701
Mailing Address - Street 1:2667 E GALA CT STE 125
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-2789
Mailing Address - Country:US
Mailing Address - Phone:208-795-5090
Mailing Address - Fax:
Practice Address - Street 1:4605 ENTERPRISE WAY
Practice Address - Street 2:STE: 102
Practice Address - City:CALDWELL
Practice Address - State:ID
Practice Address - Zip Code:83605
Practice Address - Country:US
Practice Address - Phone:208-795-5090
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:P. ROMAN BURK DPM PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-09-16
Last Update Date:2022-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy