Healthcare Provider Details

I. General information

NPI: 1689676363
Provider Name (Legal Business Name): STUART KEVIN BURGESS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2005
Last Update Date: 05/06/2021
Certification Date: 05/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

850 S. PINE ISLAND RD. STE. A100
PLANTATION FL
33324
US

IV. Provider business mailing address

PO BOX 31796
TAMPA FL
33631-3796
US

V. Phone/Fax

Practice location:
  • Phone: 954-741-5555
  • Fax: 954-741-6298
Mailing address:
  • Phone: 954-318-7388
  • Fax: 954-318-7350

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207WX0107X
TaxonomyRetina Specialist (Ophthalmology) Physician
License Number0072877
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: