Provider Demographics
NPI:1932195427
Name:BURNETT, MARK G (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:G
Last Name:BURNETT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1015 E 32ND ST
Mailing Address - Street 2:STE 411
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78705
Mailing Address - Country:US
Mailing Address - Phone:512-474-1114
Mailing Address - Fax:512-474-1118
Practice Address - Street 1:1015 E 32ND ST
Practice Address - Street 2:STE 411
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78705
Practice Address - Country:US
Practice Address - Phone:512-474-1114
Practice Address - Fax:512-474-1118
Is Sole Proprietor?:No
Enumeration Date:2005-09-21
Last Update Date:2021-12-02
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AZ33378207T00000X
TXM7885207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ102796Medicare ID - Type Unspecified
I28702Medicare UPIN