Healthcare Provider Details

I. General information

NPI: 1003884297
Provider Name (Legal Business Name): GREGORY PAUL BURTON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/14/2006
Last Update Date: 03/21/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

415 CHALAN SAN ANTONIO STE 214
TAMUNING GU
96913-3620
US

IV. Provider business mailing address

415 CHALAN SAN ANTONIO STE 214
TAMUNING GU
96913-3620
US

V. Phone/Fax

Practice location:
  • Phone: 671-647-6213
  • Fax: 671-647-5385
Mailing address:
  • Phone: 671-647-6213
  • Fax: 671-647-5385

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number10976
License Number StateMT
# 2
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberM-1658
License Number StateGU

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: