Healthcare Provider Details

I. General information

NPI: 1194214320
Provider Name (Legal Business Name): JACK EDWARD BURGESON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/03/2018
Last Update Date: 09/11/2024
Certification Date: 09/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 NE PROFESSIONAL CT
BEND OR
97701-6063
US

IV. Provider business mailing address

2200 NE PROFESSIONAL CT
BEND OR
97701-6063
US

V. Phone/Fax

Practice location:
  • Phone: 541-382-3344
  • Fax:
Mailing address:
  • Phone: 541-389-6313
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number35.147258
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number11393172-1205
License Number StateUT
# 3
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD217757
License Number StateOR

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: