Provider Demographics
NPI:1801808647
Name:BURNETT, JAMES RANDALL (MD)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:RANDALL
Last Name:BURNETT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:JAMES
Other - Middle Name:RANDALL
Other - Last Name:BURNETT
Other - Suffix:JR
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:169 PARK ROW STE 11
Mailing Address - Street 2:
Mailing Address - City:BRUNSWICK
Mailing Address - State:ME
Mailing Address - Zip Code:04011-2039
Mailing Address - Country:US
Mailing Address - Phone:207-522-4376
Mailing Address - Fax:207-725-2473
Practice Address - Street 1:169 PARK ROW STE 11
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:ME
Practice Address - Zip Code:04011-2039
Practice Address - Country:US
Practice Address - Phone:207-522-4376
Practice Address - Fax:207-725-2473
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-12
Last Update Date:2017-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME0143002084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME334240099Medicaid
A92373Medicare UPIN
MERX3150Medicare UPIN