Basic Information
Provider Information | |||||||||
NPI: | 1922020395 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BURNETT | ||||||||
FirstName: | DAK | ||||||||
MiddleName: | R | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 5501 NW 62ND TER | ||||||||
Address2: | SUITE 201 | ||||||||
City: | KANSAS CITY | ||||||||
State: | MO | ||||||||
PostalCode: | 641512408 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8165848884 | ||||||||
FaxNumber: | 9139459612 | ||||||||
Practice Location | |||||||||
Address1: | 1530 N CHURCH RD | ||||||||
Address2: |   | ||||||||
City: | LIBERTY | ||||||||
State: | MO | ||||||||
PostalCode: | 640687129 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8167811696 | ||||||||
FaxNumber: | 9139459611 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/24/2006 | ||||||||
LastUpdateDate: | 09/15/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | R2F31 | MO | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RC0000X | 04-19205 | KS | N |   | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
ID | Type | State | Issuer | Description | 100172590B | 05 | KS |   | MEDICAID | 051557 | 01 | KS | BCBS KS | OTHER | 100172590A | 05 | KS |   | MEDICAID | 11691012 | 01 |   | BCBS KC | OTHER | 202186110 | 05 | MO |   | MEDICAID |