Healthcare Provider Details

I. General information

NPI: 1740217603
Provider Name (Legal Business Name): RANDALL D BURR M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2006
Last Update Date: 08/29/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1618 S. MILLENNIUM WAY SUITE 100
MERIDIAN ID
83642-6457
US

IV. Provider business mailing address

1618 S. MILLENNIUM WAY SUITE 100
MERIDIAN ID
83642-6457
US

V. Phone/Fax

Practice location:
  • Phone: 208-884-3376
  • Fax: 208-884-0858
Mailing address:
  • Phone: 208-884-3376
  • Fax: 208-884-0858

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberM5986
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: