Healthcare Provider Details

I. General information

NPI: 1780880088
Provider Name (Legal Business Name): PAUL BURTON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2007
Last Update Date: 05/01/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 MAIN ST CHSB-5TH FLOOR
SAN QUENTIN CA
94964-1000
US

IV. Provider business mailing address

1 MAIN ST P.O. BOX 397
SAN QUENTIN CA
94964-1000
US

V. Phone/Fax

Practice location:
  • Phone: 415-820-1581
  • Fax: 415-820-1582
Mailing address:
  • Phone: 415-820-1581
  • Fax: 415-820-1582

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number106209
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number243434
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: