=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225233729
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | WILLIAM ELTON BURNETT D.O
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/15/2007
-----------------------------------------------------
Last Update Date | 08/19/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2150 BOGGS RD SUITE 250
-----------------------------------------------------
City | DULUTH
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30096-5890
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-697-6695
-----------------------------------------------------
Fax | 678-957-0887
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2720 MALL OF GEORGIA BLVD SUITE 207
-----------------------------------------------------
City | BUFORD
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30519-8761
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-697-6695
-----------------------------------------------------
Fax | 678-957-0887
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 020413
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------