Provider Demographics
NPI:1396727145
Name:BURGESON, CONNIE KIMBLE (MD)
Entity type:Individual
Prefix:DR
First Name:CONNIE
Middle Name:KIMBLE
Last Name:BURGESON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:CONNIE
Other - Middle Name:LYNN
Other - Last Name:KIMBLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 45680
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94145
Mailing Address - Country:UM
Mailing Address - Phone:530-672-7000
Mailing Address - Fax:
Practice Address - Street 1:3581 PALMER DR STE 608
Practice Address - Street 2:
Practice Address - City:CAMERON PARK
Practice Address - State:CA
Practice Address - Zip Code:95682-8238
Practice Address - Country:US
Practice Address - Phone:530-672-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-17
Last Update Date:2022-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA63161207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAH02989Medicare UPIN