Provider Demographics
NPI:1548654189
Name:BURKETT, CHARLES RYAN (MD)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:RYAN
Last Name:BURKETT
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 1:515 PACIFIC AVE
Mailing Address - Street 2:
Mailing Address - City:AUDUBON
Mailing Address - State:IA
Mailing Address - Zip Code:50025-1056
Mailing Address - Country:US
Mailing Address - Phone:402-505-2622
Mailing Address - Fax:
Practice Address - Street 1:515 PACIFIC AVE STE 2
Practice Address - Street 2:
Practice Address - City:AUDUBON
Practice Address - State:IA
Practice Address - Zip Code:50025-1056
Practice Address - Country:US
Practice Address - Phone:712-563-4611
Practice Address - Fax:412-563-2498
Is Sole Proprietor?:No
Enumeration Date:2015-03-21
Last Update Date:2018-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA44629207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine