MEDICARE: DR. FRED HURD BURBANK 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	2084P0800X	Psychiatry Physician	G16735	CA
2	2085R0204X	Vascular & Interventional Radiology Physician	G16735	CA

General Provider Information

NPI Number	:	1871852236
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. FRED HURD BURBANK M.D.

Provider Business Mailing Address
First Line	:	24040 CAMINO DEL AVION
Second Line	:	A326
City	:	DANA POINT
State	:	CA
Zip	:	92629-4005
Country	:	US
Telephone Number	:	949-496-0026
Fax Number	:	949-496-3247

Provider Business Practice Location Address
First Line	:	24040 CAMINO DEL AVION
Second Line	:	A326
City	:	DANA POINT
State	:	CA
Zip	:	92629-4005
Country	:	US
Telephone Number	:	949-496-0026
Fax Number	:	949-496-3247

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

Provider Enumeration Date	:	05/04/2012
Last Update Date	:	05/04/2012

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