Provider Demographics
NPI:1851115588
Name:BURDINE, CARL R
Entity type:Individual
Prefix:MR
First Name:CARL
Middle Name:R
Last Name:BURDINE
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 1:491 ALTA VIEW VILLAGE CT
Mailing Address - Street 2:
Mailing Address - City:WORTHINGTON
Mailing Address - State:OH
Mailing Address - Zip Code:43085-5900
Mailing Address - Country:US
Mailing Address - Phone:614-967-8311
Mailing Address - Fax:
Practice Address - Street 1:491 ALTA VIEW VILLAGE CT
Practice Address - Street 2:
Practice Address - City:WORTHINGTON
Practice Address - State:OH
Practice Address - Zip Code:43085-5900
Practice Address - Country:US
Practice Address - Phone:614-967-8311
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-11
Last Update Date:2024-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRK270019172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver