Provider Demographics
NPI:1902911845
Name:BURT, ANDREW G (MD)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:G
Last Name:BURT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:140 LITTON DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:GRASS VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:95945-5077
Mailing Address - Country:US
Mailing Address - Phone:530-477-4016
Mailing Address - Fax:
Practice Address - Street 1:11400 PLEASANT VALLEY RD
Practice Address - Street 2:
Practice Address - City:PENN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95946-9001
Practice Address - Country:US
Practice Address - Phone:530-432-7023
Practice Address - Fax:530-432-7026
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2014-05-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA88778207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A887780Medicaid
I19989Medicare UPIN
CA00A887780Medicaid