Provider Demographics
NPI:1134824576
Name:BURDETTE, TEVIN JAMAL
Entity type:Individual
Prefix:
First Name:TEVIN
Middle Name:JAMAL
Last Name:BURDETTE
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 1:8282 WOOSTER PIKE APT 3
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45227-4031
Mailing Address - Country:US
Mailing Address - Phone:615-430-4386
Mailing Address - Fax:
Practice Address - Street 1:8282 WOOSTER PIKE APT 3
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45227-4031
Practice Address - Country:US
Practice Address - Phone:615-430-4386
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-04
Last Update Date:2023-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program