Provider Demographics
NPI:1093790255
Name:BERGER, JONATHAN A (MD)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:A
Last Name:BERGER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOXS 80070
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46898
Mailing Address - Country:US
Mailing Address - Phone:260-432-1568
Mailing Address - Fax:260-432-4969
Practice Address - Street 1:5001 US HIGHWAY 30 W STE D
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46818-9701
Practice Address - Country:US
Practice Address - Phone:260-432-1568
Practice Address - Fax:260-432-4969
Is Sole Proprietor?:No
Enumeration Date:2005-12-09
Last Update Date:2016-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01037032A2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100328240AMedicaid
MI1093790255Medicaid
OH0738358Medicaid
MIP00835317Medicare PIN
OHH187580Medicare PIN
E05546Medicare UPIN
MIMI1209035Medicare PIN
INP00630143Medicare PIN
OH0738358Medicaid
IN459320DMedicare ID - Type Unspecified
IN100328240AMedicaid