Provider Demographics
NPI:1104808229
Name:BURSON, MARK LLOYD (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:LLOYD
Last Name:BURSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1718
Mailing Address - Street 2:
Mailing Address - City:TULLAHOMA
Mailing Address - State:TN
Mailing Address - Zip Code:37388-1718
Mailing Address - Country:US
Mailing Address - Phone:931-454-1955
Mailing Address - Fax:931-454-1956
Practice Address - Street 1:107 LEDFORD MILL RD
Practice Address - Street 2:
Practice Address - City:TULLAHOMA
Practice Address - State:TN
Practice Address - Zip Code:37388-2278
Practice Address - Country:US
Practice Address - Phone:931-454-1955
Practice Address - Fax:931-454-1956
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-15
Last Update Date:2024-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101265824208800000X
COCDR.0004667208800000X
TN40439208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4116328OtherBCBS
TN3336162Medicare PIN
TN4116328OtherBCBS