Healthcare Provider Details

I. General information

NPI: 1588608434
Provider Name (Legal Business Name): THOMAS RAY BURKLOW M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2006
Last Update Date: 01/26/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

WALTER REED NATIONAL MILITARY CTR 8901 WISCONSIN AVE
BETHESDA MD
20889-0001
US

IV. Provider business mailing address

9904 WILLOW TREE TER
ROCKVILLE MD
20850-5473
US

V. Phone/Fax

Practice location:
  • Phone: 301-319-8916
  • Fax: 301-319-2420
Mailing address:
  • Phone: 301-251-6179
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License NumberD39820
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: