Provider Demographics
NPI:1447273560
Name:BURGESS, JOHN A V
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:A
Last Name:BURGESS
Suffix:V
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 1:215 S LOUISIANA AVE
Mailing Address - Street 2:
Mailing Address - City:MARTINSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:25401
Mailing Address - Country:US
Mailing Address - Phone:304-263-3335
Mailing Address - Fax:304-267-5557
Practice Address - Street 1:215 S LOUISIANA AVE
Practice Address - Street 2:
Practice Address - City:MARTINSBURG
Practice Address - State:WV
Practice Address - Zip Code:25401
Practice Address - Country:US
Practice Address - Phone:304-263-3335
Practice Address - Fax:304-267-5557
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1000208600000X, 208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered208600000XAllopathic & Osteopathic PhysiciansSurgery
Not Answered208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVE05965Medicare UPIN