Provider Demographics
NPI:1932896925
Name:BURTON, JUSTIN M
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:M
Last Name:BURTON
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 1:12951 HUEBNER RD # 782491
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78230-1547
Mailing Address - Country:US
Mailing Address - Phone:210-837-7233
Mailing Address - Fax:
Practice Address - Street 1:12951 HUEBNER RD # 782491
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78230-1547
Practice Address - Country:US
Practice Address - Phone:210-837-7233
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-19
Last Update Date:2023-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX804823614305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service