Basic Information
| Provider Information | |||||||||
| NPI: | 1790774990 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BURLESON | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | N | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 2350 BUHNE ST | ||||||||
| Address2: | A | ||||||||
| City: | EUREKA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 955013238 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 2350 BUHNE ST | ||||||||
| Address2: | A | ||||||||
| City: | EUREKA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 955013238 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7074434593 | ||||||||
| FaxNumber: | 7074436447 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/19/2005 | ||||||||
| 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 | 173000000X | C326570 | CA | Y | Other Service Providers | Legal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00C326570 | 05 | CA | MEDICAID |