Provider Demographics
NPI:1407402506
Name:BURKEN, MITCHELL IRA (MD)
Entity type:Individual
Prefix:
First Name:MITCHELL
Middle Name:IRA
Last Name:BURKEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:MITCHELL
Other - Middle Name:IRA
Other - Last Name:BURKEN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:11720 MAIN ST STE 108
Mailing Address - Street 2:
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22408-7368
Mailing Address - Country:US
Mailing Address - Phone:540-735-9350
Mailing Address - Fax:
Practice Address - Street 1:11720 MAIN ST STE 108
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22408-7368
Practice Address - Country:US
Practice Address - Phone:540-735-9350
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-14
Last Update Date:2024-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101282544207ZC0006X, 207RA0401X
MDD0031869207RA0401X, 207ZP0105X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction MedicineGroup - Multi-Specialty
No207ZC0006XAllopathic & Osteopathic PhysiciansPathologyClinical Pathology
No207ZP0105XAllopathic & Osteopathic PhysiciansPathologyClinical Pathology/Laboratory MedicineGroup - Multi-Specialty