Provider Demographics
NPI:1306885900
Name:BURKE, BENJIE LLEWELLYN (MD)
Entity type:Individual
Prefix:
First Name:BENJIE
Middle Name:LLEWELLYN
Last Name:BURKE
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:P.O. BOX 2527
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75606-2527
Mailing Address - Country:US
Mailing Address - Phone:903-655-1313
Mailing Address - Fax:903-657-6067
Practice Address - Street 1:906 JUDSON RD
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75601-5113
Practice Address - Country:US
Practice Address - Phone:903-655-1313
Practice Address - Fax:903-657-6067
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2009-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ3441207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX115299303Medicaid
TX80X440Medicare PIN
TXF02764Medicare UPIN