Basic Information
| Provider Information | |||||||||
| NPI: | 1962456327 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BURGETT | ||||||||
| FirstName: | PAUL | ||||||||
| MiddleName: | MARCUS | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2758 | ||||||||
| Address2: | |||||||||
| City: | WATERLOO | ||||||||
| State: | IA | ||||||||
| PostalCode: | 507042758 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3198335907 | ||||||||
| FaxNumber: | 3198335908 | ||||||||
| Practice Location | |||||||||
| Address1: | 1753 W RIDGEWAY AVE | ||||||||
| Address2: | STE 107 | ||||||||
| City: | WATERLOO | ||||||||
| State: | IA | ||||||||
| PostalCode: | 507014588 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3198335907 | ||||||||
| FaxNumber: | 3198335908 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/20/2006 | ||||||||
| LastUpdateDate: | 02/04/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/04/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 32454 | IA | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 45674 | 01 | IA | WELLMARK INS PLAN | OTHER | 421417307B8 | 01 | IA | JOHN DEERE HEALTH CARE | OTHER | 0177436 | 05 | IA | MEDICAID |