MEDICARE: JETTIE MARITA BURNETT MD

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	207W00000X	Ophthalmology Physician	24783	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1932153343
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JETTIE MARITA BURNETT MD

Provider Business Mailing Address
First Line	:	1415 HOWELL MILL RD NW
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30318-4223
Country	:	US
Telephone Number	:	404-881-6417
Fax Number	:	770-996-1472

Provider Business Practice Location Address
First Line	:	1415 HOWELL MILL RD NW
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30318-4223
Country	:	US
Telephone Number	:	404-881-6417
Fax Number	:	770-996-1472

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

Provider Enumeration Date	:	05/20/2006
Last Update Date	:	03/20/2025

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