Provider Demographics
NPI:1811515208
Name:BURKHART, DANIEL BRUCE
Entity type:Individual
Prefix:MR
First Name:DANIEL
Middle Name:BRUCE
Last Name:BURKHART
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:305 BLACK ROCK TPKE
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06825-5508
Mailing Address - Country:US
Mailing Address - Phone:203-337-2600
Mailing Address - Fax:203-337-2666
Practice Address - Street 1:2902 W AGUA FRIA FWY STE 1090
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85027-3970
Practice Address - Country:US
Practice Address - Phone:602-648-5444
Practice Address - Fax:602-772-3801
Is Sole Proprietor?:No
Enumeration Date:2020-07-11
Last Update Date:2024-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT6355363A00000X, 363AS0400X
AZ8174363A00000X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ083339Medicaid