Healthcare Provider Details

I. General information

NPI: 1720283559
Provider Name (Legal Business Name): TODD SHANNON BURDETTE AU.D., AUDIOLOGIST
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2007
Last Update Date: 05/01/2024
Certification Date: 05/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

418 GRAND PARK DR STE 315
PARKERSBURG WV
26105-4000
US

IV. Provider business mailing address

418 GRAND PARK DR STE 315
PARKERSBURG WV
26105-4000
US

V. Phone/Fax

Practice location:
  • Phone: 304-428-3500
  • Fax: 304-422-7900
Mailing address:
  • Phone: 304-532-1676
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License NumberA-0173
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: