Provider Demographics
NPI:1447487749
Name:BURKET, ROONG ROBERT (IDMT)
Entity type:Individual
Prefix:
First Name:ROONG
Middle Name:ROBERT
Last Name:BURKET
Suffix:
Gender:M
Credentials:IDMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2467 MUSCOGEE DR
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31602-5720
Mailing Address - Country:US
Mailing Address - Phone:229-444-4540
Mailing Address - Fax:
Practice Address - Street 1:347 OSS OSM
Practice Address - Street 2:
Practice Address - City:MOODY A F B
Practice Address - State:GA
Practice Address - Zip Code:31699-0001
Practice Address - Country:US
Practice Address - Phone:229-257-3874
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-15
Last Update Date:2009-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians