MEDICARE: DR. JOHN PETER BURGHARDT JR. DPM

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	213E00000X	Podiatrist	002467	NY

General Provider Information

NPI Number	:	1003817024
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JOHN PETER BURGHARDT JR. DPM

Provider Business Mailing Address
First Line	:	1013 OLD TOWN RD
Second Line	:
City	:	CORAM
State	:	NY
Zip	:	11727-1853
Country	:	US
Telephone Number	:	631-732-2590
Fax Number	:	631-732-2590

Provider Business Practice Location Address
First Line	:	1013 OLD TOWN RD
Second Line	:
City	:	CORAM
State	:	NY
Zip	:	11727-1853
Country	:	US
Telephone Number	:	631-732-2590
Fax Number	:	631-732-2590

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/02/2005
Last Update Date	:	12/30/2010

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