Provider Demographics
NPI:1952359135
Name:BURGOS, ROBERT D (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:D
Last Name:BURGOS
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 1:11803 SOUTH FREEWAY
Mailing Address - Street 2:SUITE 354
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76115
Mailing Address - Country:US
Mailing Address - Phone:817-551-9300
Mailing Address - Fax:817-551-9083
Practice Address - Street 1:11803 SOUTH FREEWAY
Practice Address - Street 2:SUITE 354
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76115
Practice Address - Country:US
Practice Address - Phone:817-551-9300
Practice Address - Fax:817-551-9083
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-04
Last Update Date:2019-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH4879174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00U32TOtherBLUE CROSS BLUE SHIELD
TXH4879OtherSTATE LICENSE
TXH4879OtherSTATE LICENSE
TXD16704Medicare UPIN