Healthcare Provider Details

I. General information

NPI: 1710965710
Provider Name (Legal Business Name): JESUS A BURBANO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/09/2006
Last Update Date: 05/29/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8615 RAMSEY AVE
SILVER SPRING MD
20910-3408
US

IV. Provider business mailing address

PO BOX 13037
SILVER SPRING MD
20911-0037
US

V. Phone/Fax

Practice location:
  • Phone: 301-585-1230
  • Fax: 301-585-2446
Mailing address:
  • Phone: 301-585-1230
  • Fax: 301-585-2446

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberD0055094
License Number StateMD

VII. Legacy identifiers

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

# 1
Identifier4050771 00
Identifier TypeMEDICAID
Identifier StateMD
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: