=====================================================
General NPI Number Information
=====================================================
NPI Number | 1881608263
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KENNETH L BURKE OD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/28/2006
-----------------------------------------------------
Last Update Date | 03/26/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 175 MAIN ST S
-----------------------------------------------------
City | WOODBURY
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06798-3405
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-263-3391
-----------------------------------------------------
Fax | 203-263-3390
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 384
-----------------------------------------------------
City | WOODBURY
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06798-0384
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-263-3391
-----------------------------------------------------
Fax | 203-263-3390
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 000817
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------