Provider Demographics
NPI:1114926292
Name:BERG, JEFFREY HOWARD (MD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:HOWARD
Last Name:BERG
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 1:1860 TOWN CENTER DR
Mailing Address - Street 2:SUITE 300
Mailing Address - City:RESTON
Mailing Address - State:VA
Mailing Address - Zip Code:20190-5896
Mailing Address - Country:US
Mailing Address - Phone:703-435-6604
Mailing Address - Fax:703-787-6575
Practice Address - Street 1:1860 TOWN CENTER DR
Practice Address - Street 2:SUITE 300
Practice Address - City:RESTON
Practice Address - State:VA
Practice Address - Zip Code:20190-5896
Practice Address - Country:US
Practice Address - Phone:703-435-6604
Practice Address - Fax:703-787-6575
Is Sole Proprietor?:No
Enumeration Date:2005-07-20
Last Update Date:2008-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101057466207X00000X, 207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAG67940Medicare UPIN
DC000820T99Medicare PIN