Healthcare Provider Details

I. General information

NPI: 1255311247
Provider Name (Legal Business Name): BURT WILLIAM WARD MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/18/2006
Last Update Date: 11/14/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

417A RACETRACK RD NW STE 2
FT WALTON BEACH FL
32547-4612
US

IV. Provider business mailing address

417A RACETRACK RD NW STE 2
FT WALTON BEACH FL
32547-4612
US

V. Phone/Fax

Practice location:
  • Phone: 850-863-5990
  • Fax: 850-862-0041
Mailing address:
  • Phone: 850-863-5990
  • Fax: 850-862-0041

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberME0045373
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: