MEDICARE: MITCHELL DAVID BURNBAUM MD

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	2084N0400X	Neurology Physician	DR.0020923	CO

General Provider Information

NPI Number	:	1700866159
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MITCHELL DAVID BURNBAUM MD

Provider Business Mailing Address
First Line	:	PO BOX 130
Second Line	:
City	:	FRUITA
State	:	CO
Zip	:	81521-0130
Country	:	US
Telephone Number	:	970-243-9180
Fax Number	:	970-245-2697

Provider Business Practice Location Address
First Line	:	551 KOKOPELLI BLVD UNIT G
Second Line	:
City	:	FRUITA
State	:	CO
Zip	:	81521-6305
Country	:	US
Telephone Number	:	970-243-9180
Fax Number	:	970-245-2697

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

Provider Enumeration Date	:	01/20/2006
Last Update Date	:	11/23/2020

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