Provider Demographics
NPI:1063104164
Name:STAN W BURLESON MD PA
Entity type:Organization
Organization Name:STAN W BURLESON MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:STANLEY
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:BURLESON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:870-946-1326
Mailing Address - Street 1:PO BOX 32
Mailing Address - Street 2:
Mailing Address - City:DE WITT
Mailing Address - State:AR
Mailing Address - Zip Code:72042-0032
Mailing Address - Country:US
Mailing Address - Phone:870-233-2214
Mailing Address - Fax:870-946-4577
Practice Address - Street 1:705 W 16TH ST
Practice Address - Street 2:
Practice Address - City:DE WITT
Practice Address - State:AR
Practice Address - Zip Code:72042-3414
Practice Address - Country:US
Practice Address - Phone:870-946-1326
Practice Address - Fax:870-946-4577
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-05-25
Last Update Date:2023-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty