Healthcare Provider Details

I. General information

NPI: 1386010098
Provider Name (Legal Business Name): LAURENCE S BURDETT MD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/17/2015
Last Update Date: 08/16/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3480 WASHINGTON BLVD STE 105
OGDEN UT
84401-4149
US

IV. Provider business mailing address

PO BOX 837
OGDEN UT
84402-0837
US

V. Phone/Fax

Practice location:
  • Phone: 801-392-0385
  • Fax: 801-393-3334
Mailing address:
  • Phone: 801-392-0402
  • Fax: 801-393-3334

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number3404331205
License Number StateUT

VIII. Authorized Official

Name: LAURENCE S BURDETT
Title or Position: OWNER
Credential: MD
Phone: 801-458-2073