Provider Demographics
NPI: | 1043278716 |
---|---|
Name: | BURTON, BRIAN MICHAEL (LDO) |
Entity type: | Individual |
Prefix: | MR |
First Name: | BRIAN |
Middle Name: | MICHAEL |
Last Name: | BURTON |
Suffix: | |
Gender: | M |
Credentials: | LDO |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | 134 CRIMSON LEAF LN |
Mailing Address - Street 2: | |
Mailing Address - City: | LIBERTY |
Mailing Address - State: | SC |
Mailing Address - Zip Code: | 29657-4202 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 864-506-6256 |
Mailing Address - Fax: | 864-639-4012 |
Practice Address - Street 1: | 134 CRIMSON LEAF LN |
Practice Address - Street 2: | |
Practice Address - City: | LIBERTY |
Practice Address - State: | SC |
Practice Address - Zip Code: | 29657-4202 |
Practice Address - Country: | US |
Practice Address - Phone: | 864-506-6256 |
Practice Address - Fax: | 864-639-4012 |
Is Sole Proprietor?: | Not Answered |
Enumeration Date: | 2006-05-03 |
Last Update Date: | 2025-09-11 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
SC | 242 | 156FC0800X |
SC | 776 | 156FX1800X |
OH | 6004 | 156FX1800X |
HI | 260 | 156FX1800X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 156FX1800X | Eye and Vision Services Providers | Technician/Technologist | Optician |
No | 156FC0800X | Eye and Vision Services Providers | Technician/Technologist | Contact Lens |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
SC | DV7760 | Medicaid |