Provider Demographics
NPI:1114003787
Name:BERTHOLD, ROBERT NGO (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:NGO
Last Name:BERTHOLD
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 1:1136 MAGNOLIA AVE
Mailing Address - Street 2:
Mailing Address - City:GARDENA
Mailing Address - State:CA
Mailing Address - Zip Code:90247-4305
Mailing Address - Country:US
Mailing Address - Phone:310-800-7017
Mailing Address - Fax:
Practice Address - Street 1:14623 HAWTHORNE BLVD
Practice Address - Street 2:SUITE 400
Practice Address - City:LAWNDALE
Practice Address - State:CA
Practice Address - Zip Code:90260-1581
Practice Address - Country:US
Practice Address - Phone:310-970-5023
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-27
Last Update Date:2011-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA857462084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
ED819ZMedicare PIN