Provider Demographics
NPI:1124147368
Name:BURT, ANDREW KELLY (MD)
Entity type:Individual
Prefix:
First Name:ANDREW
Middle Name:KELLY
Last Name:BURT
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 1:77 MARK DR STE 25
Mailing Address - Street 2:
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94903-2268
Mailing Address - Country:US
Mailing Address - Phone:415-491-1492
Mailing Address - Fax:415-419-1499
Practice Address - Street 1:77 MARK DR STE 25
Practice Address - Street 2:
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94903-2268
Practice Address - Country:US
Practice Address - Phone:415-491-1492
Practice Address - Fax:415-419-1499
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC383160173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes173000000XOther Service ProvidersLegal Medicine