Basic Information
| Provider Information | |||||||||
| NPI: | 1265409668 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VAN BURKLEO | ||||||||
| FirstName: | JULIA | ||||||||
| MiddleName: | B | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 847176 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752847176 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9032371800 | ||||||||
| FaxNumber: | 9032371810 | ||||||||
| Practice Location | |||||||||
| Address1: | 1111 N 6TH ST | ||||||||
| Address2: | |||||||||
| City: | LONGVIEW | ||||||||
| State: | TX | ||||||||
| PostalCode: | 756015537 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9037537658 | ||||||||
| FaxNumber: | 9032360385 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/03/2006 | ||||||||
| LastUpdateDate: | 01/24/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | C6542 | TX | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 207VG0400X | C6542 | TX | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 113723405 | 05 | TX | MEDICAID |