Healthcare Provider Details

I. General information

NPI: 1336110808
Provider Name (Legal Business Name): JAY JEFFREY BURLINGAME O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/31/2006
Last Update Date: 02/09/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11500 W 119TH ST
OVERLAND PARK KS
66213-2002
US

IV. Provider business mailing address

11500 W 119TH ST
OVERLAND PARK KS
66213-2002
US

V. Phone/Fax

Practice location:
  • Phone: 913-451-0001
  • Fax: 913-451-1659
Mailing address:
  • Phone: 913-451-0001
  • Fax: 913-451-1659

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number12753
License Number StateKS
# 2
Primary TaxonomyN
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License Number12753
License Number StateKS
# 3
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number12753
License Number StateKS

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: