Provider Demographics
NPI:1962060723
Name:BURGESS, ELIZABETH JEANNE (MD)
Entity type:Individual
Prefix:DR
First Name:ELIZABETH
Middle Name:JEANNE
Last Name:BURGESS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7495 W 29TH AVE
Mailing Address - Street 2:
Mailing Address - City:WHEAT RIDGE
Mailing Address - State:CO
Mailing Address - Zip Code:80033-8002
Mailing Address - Country:US
Mailing Address - Phone:303-761-1977
Mailing Address - Fax:303-434-0247
Practice Address - Street 1:7495 W 29TH AVE
Practice Address - Street 2:
Practice Address - City:WHEAT RIDGE
Practice Address - State:CO
Practice Address - Zip Code:80033
Practice Address - Country:US
Practice Address - Phone:303-761-1977
Practice Address - Fax:303-343-0247
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-05
Last Update Date:2024-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036160606207Q00000X
390200000X
CODR.0072622207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO029583OtherKAISER COMMERCIAL NUMBER
CO9000230073Medicaid