Healthcare Provider Details

I. General information

NPI: 1922080779
Provider Name (Legal Business Name): LENNIS P BURKE JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 11/17/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 BELLEFONTAINE ST STE 405
PASADENA CA
91105-3132
US

IV. Provider business mailing address

50 BELLEFONTAINE ST STE 405
PASADENA CA
91105-3132
US

V. Phone/Fax

Practice location:
  • Phone: 626-796-9259
  • Fax: 626-449-8560
Mailing address:
  • Phone: 626-796-9259
  • Fax: 626-449-8560

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License NumberG42405
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: