Healthcare Provider Details

I. General information

NPI: 1629161864
Provider Name (Legal Business Name): KELLY DOUGLAS BURCHETT DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/02/2006
Last Update Date: 09/09/2020
Certification Date: 09/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1605 SOUTH BALTOMORE SUITE B
KIRKSVILLE MO
63501
US

IV. Provider business mailing address

1605 SOUTH BALTIMORE SUITE B
KIRKSVILLE MO
63501
US

V. Phone/Fax

Practice location:
  • Phone: 660-665-3599
  • Fax: 660-665-3570
Mailing address:
  • Phone: 660-665-3599
  • Fax: 660-665-3570

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YX0905X
TaxonomyOtolaryngology/Facial Plastic Surgery Physician
License Number2001010344
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: