Provider Demographics
NPI:1992767990
Name:BURNHAM, MARTHA A (RD)
Entity type:Individual
Prefix:
First Name:MARTHA
Middle Name:A
Last Name:BURNHAM
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:MARTHA
Other - Middle Name:F
Other - Last Name:BURNHAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:369 HINES TER
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31204-2417
Mailing Address - Country:US
Mailing Address - Phone:478-743-5599
Mailing Address - Fax:
Practice Address - Street 1:400 CHARTER BLVD
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31210-4831
Practice Address - Country:US
Practice Address - Phone:478-757-6225
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA000350133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA71BBBNBMedicare ID - Type Unspecified