Provider Demographics
NPI:1063448983
Name:BERGER, RONALD MARK (OD)
Entity Type:Individual
Prefix:DR
First Name:RONALD
Middle Name:MARK
Last Name:BERGER
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 1:5012 DORSEY HALL DR
Mailing Address - Street 2:SUITE 105
Mailing Address - City:ELLICOTT CITY
Mailing Address - State:MD
Mailing Address - Zip Code:21042-7711
Mailing Address - Country:US
Mailing Address - Phone:410-730-8878
Mailing Address - Fax:410-997-8272
Practice Address - Street 1:5012 DORSEY HALL DR
Practice Address - Street 2:SUITE 105
Practice Address - City:ELLICOTT CITY
Practice Address - State:MD
Practice Address - Zip Code:21042-7711
Practice Address - Country:US
Practice Address - Phone:410-730-8878
Practice Address - Fax:410-997-8272
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2010-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDTA0679152W00000X, 152WC0802X, 152WP0200X, 152WS0006X, 152WV0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
No152WS0006XEye and Vision Services ProvidersOptometristSports Vision
No152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD269818800Medicaid
MD269818800Medicaid
MD617M100FMedicare ID - Type Unspecified
MD5700600001Medicare NSC