Provider Demographics
NPI:1730183112
Name:BURKENSTOCK, KELLY GILTHORPE (MD)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:GILTHORPE
Last Name:BURKENSTOCK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2040 N CAUSEWAY BLVD
Mailing Address - Street 2:
Mailing Address - City:MANDEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70471
Mailing Address - Country:US
Mailing Address - Phone:985-727-7676
Mailing Address - Fax:985-727-3476
Practice Address - Street 1:6600 FLEUR DE LIS DR
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70124-1430
Practice Address - Country:US
Practice Address - Phone:504-888-2829
Practice Address - Fax:504-888-7439
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-13
Last Update Date:2022-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA023319207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1496278Medicaid
LA1496278Medicaid
LA5E790Medicare ID - Type Unspecified