Healthcare Provider Details

I. General information

NPI: 1700866159
Provider Name (Legal Business Name): MITCHELL DAVID BURNBAUM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/20/2006
Last Update Date: 11/23/2020
Certification Date: 11/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

551 KOKOPELLI BLVD UNIT G
FRUITA CO
81521-6305
US

IV. Provider business mailing address

PO BOX 130
FRUITA CO
81521-0130
US

V. Phone/Fax

Practice location:
  • Phone: 970-243-9180
  • Fax: 970-245-2697
Mailing address:
  • Phone: 970-243-9180
  • Fax: 970-245-2697

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License NumberDR.0020923
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: