Basic Information
| Provider Information | |||||||||
| NPI: | 1972587566 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BURKETT | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | A. | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1234 E DUPONT RD | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468251545 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2603739700 | ||||||||
| FaxNumber: | 2603739740 | ||||||||
| Practice Location | |||||||||
| Address1: | 1270 E STATE ROAD 205 | ||||||||
| Address2: | SUITE 150 | ||||||||
| City: | COLUMBIA CITY | ||||||||
| State: | IN | ||||||||
| PostalCode: | 467259499 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2602489890 | ||||||||
| FaxNumber: | 2602489895 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/06/2005 | ||||||||
| LastUpdateDate: | 03/25/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 02002438A | IN | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00000968827 05 | 01 | UNITED HEALTHCARE | OTHER | 3937240004 | 01 | IN | MEDICARE DMEPOS | OTHER | 12730 | 01 | IN | PHYSICIANS HEALTH PLAN | OTHER | 4270901 | 01 | AETNA | OTHER | 000000210720 | 01 | IN | ANTHEM | OTHER | 200367950 | 05 | IN | MEDICAID | 110231565 | 01 | IN | RAILROAD MEDICARE | OTHER |