Provider Demographics
NPI:1689644684
Name:BURGWALD, ERIK DUANE (OD)
Entity type:Individual
Prefix:DR
First Name:ERIK
Middle Name:DUANE
Last Name:BURGWALD
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1711 S NEIL ST
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61820
Mailing Address - Country:US
Mailing Address - Phone:217-359-2390
Mailing Address - Fax:217-359-3180
Practice Address - Street 1:1711 S NEIL ST
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61820
Practice Address - Country:US
Practice Address - Phone:217-359-2390
Practice Address - Fax:217-359-3180
Is Sole Proprietor?:No
Enumeration Date:2006-01-24
Last Update Date:2015-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046008644152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL046008649OtherDPR
IL346000884OtherDPR
IL346000884OtherDPR
IL046008649OtherDPR