Healthcare Provider Details

I. General information

NPI: 1174694400
Provider Name (Legal Business Name): DAVID MACDONALD BURKHART M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/10/2006
Last Update Date: 09/11/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 N JORDAN AVE
BLOOMINGTON IN
47405-3190
US

IV. Provider business mailing address

600 N JORDAN AVE
BLOOMINGTON IN
47405-3190
US

V. Phone/Fax

Practice location:
  • Phone: 812-855-6511
  • Fax: 812-855-4628
Mailing address:
  • Phone: 812-855-6511
  • Fax: 812-855-4628

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0026178
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number01053733A
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number71262
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: