Provider Demographics
NPI:1841277639
Name:BURBIDGE, JOHN MICHAEL (DO)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:MICHAEL
Last Name:BURBIDGE
Suffix:
Gender:M
Credentials:DO
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 20308
Mailing Address - Street 2:
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76702-0308
Mailing Address - Country:US
Mailing Address - Phone:254-772-7300
Mailing Address - Fax:254-772-7351
Practice Address - Street 1:105 OLD HEWITT RD STE 100
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76712-6565
Practice Address - Country:US
Practice Address - Phone:254-772-7300
Practice Address - Fax:254-772-7351
Is Sole Proprietor?:No
Enumeration Date:2005-12-22
Last Update Date:2010-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK8719207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8K4522OtherMEDICARE
TX155492505Medicaid
TXP00603036OtherMEDICARE RAILROAD
TX155492501Medicaid
TX8AV860OtherBCBS
TXH72168Medicare UPIN
TX155492505Medicaid