Basic Information
| Provider Information | |||||||||
| NPI: | 1093801227 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BURNETT | ||||||||
| FirstName: | WALTER | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 11407 DEPT 1998 | ||||||||
| Address2: | |||||||||
| City: | BIRMINGHAM | ||||||||
| State: | AL | ||||||||
| PostalCode: | 352461998 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6627518289 | ||||||||
| FaxNumber: | 6627518279 | ||||||||
| Practice Location | |||||||||
| Address1: | 823 GRAND AVE | ||||||||
| Address2: | |||||||||
| City: | YAZOO CITY | ||||||||
| State: | MS | ||||||||
| PostalCode: | 391943233 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6627518289 | ||||||||
| FaxNumber: | 6627518279 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2006 | ||||||||
| LastUpdateDate: | 11/29/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 09770 | MS | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00114468 | 05 | MS | MEDICAID |