Provider Demographics
NPI:1306064258
Name:BURK, P. ROMAN (DPM)
Entity type:Individual
Prefix:
First Name:P.
Middle Name:ROMAN
Last Name:BURK
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1818 S 10TH AVE
Mailing Address - Street 2:SUITE 250
Mailing Address - City:CALDWELL
Mailing Address - State:ID
Mailing Address - Zip Code:83605-4803
Mailing Address - Country:US
Mailing Address - Phone:208-459-0891
Mailing Address - Fax:208-459-8628
Practice Address - Street 1:1818 S 10TH AVE
Practice Address - Street 2:SUITE 250
Practice Address - City:CALDWELL
Practice Address - State:ID
Practice Address - Zip Code:83605-4803
Practice Address - Country:US
Practice Address - Phone:208-459-0891
Practice Address - Fax:208-459-8628
Is Sole Proprietor?:No
Enumeration Date:2007-04-23
Last Update Date:2013-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN41000197213E00000X
IDP-197213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010167550OtherREGENCE BLUE SHIELD
IDP2447OtherBLUE CROSS
ID8080019Medicaid
ID6701670001OtherMEDICARE DME PTAN
ID6701670001OtherMEDICARE DME PTAN