Basic Information
| Provider Information | |||||||||
| NPI: | 1891159356 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BURTNER | ||||||||
| FirstName: | JUSTIN | ||||||||
| MiddleName: | |||||||||
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| Credential: | OD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5528 US HIGHWAY 98 N | ||||||||
| Address2: | |||||||||
| City: | LAKELAND | ||||||||
| State: | FL | ||||||||
| PostalCode: | 338093104 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8638532020 | ||||||||
| FaxNumber: | 8635772008 | ||||||||
| Practice Location | |||||||||
| Address1: | 5528 US HIGHWAY 98 N | ||||||||
| Address2: | |||||||||
| City: | LAKELAND | ||||||||
| State: | FL | ||||||||
| PostalCode: | 338093104 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8638532020 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/11/2016 | ||||||||
| LastUpdateDate: | 01/14/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/14/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 2102 | AZ | N | Eye and Vision Services Providers | Optometrist | 152W00000X | OPC5629 | FL | Y | Eye and Vision Services Providers | Optometrist |
No ID Information.