Healthcare Provider Details

I. General information

NPI: 1841277639
Provider Name (Legal Business Name): JOHN MICHAEL BURBIDGE DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/22/2005
Last Update Date: 01/05/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 OLD HEWITT RD STE 100
WACO TX
76712-6565
US

IV. Provider business mailing address

PO BOX 20308
WACO TX
76702-0308
US

V. Phone/Fax

Practice location:
  • Phone: 254-772-7300
  • Fax: 254-772-7351
Mailing address:
  • Phone: 254-772-7300
  • Fax: 254-772-7351

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberK8719
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: