Healthcare Provider Details

I. General information

NPI: 1538104773
Provider Name (Legal Business Name): RICHARD R BURDEAUX SR. DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2006
Last Update Date: 07/17/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2545 JACKSBORO PIKE
JACKSBORO TN
37757-4847
US

IV. Provider business mailing address

1225 E WEISGARBER RD SUITE 200
KNOXVILLE TN
37909-2604
US

V. Phone/Fax

Practice location:
  • Phone: 423-566-8181
  • Fax:
Mailing address:
  • Phone: 865-584-4747
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number1037
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: