Provider Demographics
NPI:1366771206
Name:BURKET, CLIFFORD J
Entity type:Individual
Prefix:MR
First Name:CLIFFORD
Middle Name:J
Last Name:BURKET
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:195 S. COURTENAY PARKWAY
Mailing Address - Street 2:
Mailing Address - City:MERRITT ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32952
Mailing Address - Country:US
Mailing Address - Phone:321-453-0090
Mailing Address - Fax:321-454-2512
Practice Address - Street 1:195 S. COURTENAY PARKWAY
Practice Address - Street 2:
Practice Address - City:MERRITT ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32952
Practice Address - Country:US
Practice Address - Phone:321-453-0090
Practice Address - Fax:321-454-2512
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-23
Last Update Date:2009-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOE1928156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician