MEDICARE: MR. BURT M MASHBURN M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207V00000X	Obstetrics & Gynecology Physician	030862	CT

General Provider Information

NPI Number	:	1336148154
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. BURT M MASHBURN M.D.

Provider Business Mailing Address
First Line	:	538 LITCHFIELD ST
Second Line	:	STE 202
City	:	TORRINGTON
State	:	CT
Zip	:	06790-6669
Country	:	US
Telephone Number	:	860-489-1038
Fax Number	:	860-496-4094

Provider Business Practice Location Address
First Line	:	538 LITCHFIELD ST
Second Line	:	STE 202
City	:	TORRINGTON
State	:	CT
Zip	:	06790-6669
Country	:	US
Telephone Number	:	860-489-1038
Fax Number	:	860-496-4094

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/14/2005
Last Update Date	:	07/08/2007

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