Healthcare Provider Details

I. General information

NPI: 1225029507
Provider Name (Legal Business Name): DR MARLON BURT OD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/04/2005
Last Update Date: 10/29/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

126 W MAIN ST
KUTZTOWN PA
19530-1712
US

IV. Provider business mailing address

PO BOX 268
KUTZTOWN PA
19530-0268
US

V. Phone/Fax

Practice location:
  • Phone: 610-683-3888
  • Fax: 610-683-3083
Mailing address:
  • Phone: 610-683-3888
  • Fax: 610-683-3083

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOEG001552
License Number StatePA

VIII. Authorized Official

Name: MARLON G BURT
Title or Position: OWNER
Credential: OD
Phone: 610-683-3888