Basic Information
| Provider Information | |||||||||
| NPI: | 1053369207 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BURTON | ||||||||
| FirstName: | GARY | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | L-3652 | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432600001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7403837927 | ||||||||
| FaxNumber: | 7403837942 | ||||||||
| Practice Location | |||||||||
| Address1: | 1040 DELAWARE AVENUE | ||||||||
| Address2: | |||||||||
| City: | MARION | ||||||||
| State: | OH | ||||||||
| PostalCode: | 433011814 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7403838050 | ||||||||
| FaxNumber: | 7403837084 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/04/2006 | ||||||||
| LastUpdateDate: | 06/16/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | 35052932 | OH | Y | Allopathic & Osteopathic Physicians | Ophthalmology |
ID Information
| ID | Type | State | Issuer | Description | 820000032 | 01 | TRAVELERS MEDICARE | OTHER | 311098079 | 01 | PPO NEXT | OTHER | 0718110 | 05 | OH | MEDICAID | 0800039 | 01 | UHC | OTHER | 647544 | 01 | AETNA | OTHER | 0622792 | 01 | PALMETTO MEDICARE | OTHER | 311098079030 | 01 | CIGNA | OTHER |