Basic Information
| Provider Information | |||||||||
| NPI: | 1700888492 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BURKE | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | MICHAEL | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | O.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2630 PETERS CREEK PKWY | ||||||||
| Address2: | |||||||||
| City: | WINSTON-SALEM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 271275655 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3367853486 | ||||||||
| FaxNumber: | 3367853002 | ||||||||
| Practice Location | |||||||||
| Address1: | 2630 PETERS CREEK PKWY | ||||||||
| Address2: | |||||||||
| City: | WINSTON-SALEM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 271275655 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3367853486 | ||||||||
| FaxNumber: | 3367853002 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/11/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 1004 | NC | Y | Eye and Vision Services Providers | Optometrist |
No ID Information.