Provider Demographics
NPI:1548377666
Name:KIETH J. BURKART, O.D., A PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:KIETH J. BURKART, O.D., A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KIETH
Authorized Official - Middle Name:J
Authorized Official - Last Name:BURKART
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:909-337-4310
Mailing Address - Street 1:PO BOX 2226
Mailing Address - Street 2:
Mailing Address - City:LAKE ARROWHEAD
Mailing Address - State:CA
Mailing Address - Zip Code:92352-2226
Mailing Address - Country:US
Mailing Address - Phone:909-337-4310
Mailing Address - Fax:909-336-5937
Practice Address - Street 1:29099 HOSPITAL RD
Practice Address - Street 2:SUITE 205
Practice Address - City:LAKE ARROWHEAD
Practice Address - State:CA
Practice Address - Zip Code:92352-2226
Practice Address - Country:US
Practice Address - Phone:909-337-4310
Practice Address - Fax:909-336-5937
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-24
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACOR1096152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0056390Medicaid
CAT10064Medicare UPIN
CASD0056390Medicaid