Provider Demographics
NPI:1912030909
Name:BURST, ROBERT ALLEN (OPTICIAN)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:ALLEN
Last Name:BURST
Suffix:
Gender:M
Credentials:OPTICIAN
Other - Prefix:
Other - First Name:ROBERT
Other - Middle Name:ALLEN
Other - Last Name:BURST
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OPTICIAN
Mailing Address - Street 1:949 N NAVY BLVD
Mailing Address - Street 2:THE OPTICAL OUTLET
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32507-1274
Mailing Address - Country:US
Mailing Address - Phone:850-455-5070
Mailing Address - Fax:850-458-5061
Practice Address - Street 1:949 N NAVY BLVD
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32507-1274
Practice Address - Country:US
Practice Address - Phone:850-455-5070
Practice Address - Fax:850-458-5061
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-13
Last Update Date:2008-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1703156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0866900001Medicare NSC