Healthcare Provider Details

I. General information

NPI: 1932195427
Provider Name (Legal Business Name): MARK G BURNETT MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2005
Last Update Date: 12/02/2021
Certification Date: 12/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1015 E 32ND ST STE 411
AUSTIN TX
78705
US

IV. Provider business mailing address

1015 E 32ND ST STE 411
AUSTIN TX
78705
US

V. Phone/Fax

Practice location:
  • Phone: 512-474-1114
  • Fax: 512-474-1118
Mailing address:
  • Phone: 512-474-1114
  • Fax: 512-474-1118

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License Number33378
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License NumberM7885
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: