Healthcare Provider Details

I. General information

NPI: 1093801227
Provider Name (Legal Business Name): WALTER M BURNETT M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/05/2006
Last Update Date: 11/29/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

823 GRAND AVE
YAZOO CITY MS
39194-3233
US

IV. Provider business mailing address

PO BOX 11407 DEPT 1998
BIRMINGHAM AL
35246-1998
US

V. Phone/Fax

Practice location:
  • Phone: 662-751-8289
  • Fax: 662-751-8279
Mailing address:
  • Phone: 662-751-8289
  • Fax: 662-751-8279

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number09770
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: