Healthcare Provider Details

I. General information

NPI: 1750661328
Provider Name (Legal Business Name): JESSE ANDREW BURNAM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/26/2011
Last Update Date: 08/26/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15647 CARRIEDALE LN
FORT MYERS FL
33912-3904
US

IV. Provider business mailing address

15647 CARRIEDALE LN
FORT MYERS FL
33912-3904
US

V. Phone/Fax

Practice location:
  • Phone: 239-768-3878
  • Fax: 239-768-3878
Mailing address:
  • Phone: 239-768-3878
  • Fax: 239-768-3878

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YS0123X
TaxonomyFacial Plastic Surgery Physician
License Number12233
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207YS0123X
TaxonomyFacial Plastic Surgery Physician
License Number13757
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: