Provider Demographics
NPI:1063445856
Name:KOOMSON, BERTHA
Entity Type:Individual
Prefix:
First Name:BERTHA
Middle Name:
Last Name:KOOMSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4910 MASSACHUSETTS AVE NW
Mailing Address - Street 2:#217
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20016-4300
Mailing Address - Country:US
Mailing Address - Phone:202-244-1553
Mailing Address - Fax:202-244-2192
Practice Address - Street 1:4910 MASSACHUSETTS AVE NW
Practice Address - Street 2:#217
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20016-4300
Practice Address - Country:US
Practice Address - Phone:202-244-1553
Practice Address - Fax:202-244-2192
Is Sole Proprietor?:No
Enumeration Date:2006-07-08
Last Update Date:2010-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCCS9810758208000000X
MDD56918207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDE63952Medicare UPIN
DC370022123Medicare PIN
DC008271M30Medicare PIN