Provider Demographics
NPI:1912981028
Name:BURNETT, DAVID M (OD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:M
Last Name:BURNETT
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2001 COOLIDGE RD
Mailing Address - Street 2:
Mailing Address - City:EAST LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48823-1378
Mailing Address - Country:US
Mailing Address - Phone:517-337-1668
Mailing Address - Fax:517-337-1779
Practice Address - Street 1:1005 CHARLEVOIX DR
Practice Address - Street 2:SUITE 200
Practice Address - City:GRAND LEDGE
Practice Address - State:MI
Practice Address - Zip Code:48837-8186
Practice Address - Country:US
Practice Address - Phone:517-627-3030
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-01
Last Update Date:2009-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901002388152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1016807OtherMCLAREN
MIDB002388OtherSTATE LICENSE NUMBER
MI4487110Medicaid
MI900C36357OtherBCBSM
MI4487094Medicaid
MI200000001542OtherPHPMM
MIP00065776OtherRAILROAD MEDICARE
MI900C36357OtherBCBSM
MI4487110Medicaid