Provider Demographics
NPI:1174186092
Name:BERENSON, ADAM MILES
Entity Type:Individual
Prefix:
First Name:ADAM
Middle Name:MILES
Last Name:BERENSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14821 WILLOW MOSS ST
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78232-4546
Mailing Address - Country:US
Mailing Address - Phone:253-225-7685
Mailing Address - Fax:
Practice Address - Street 1:14821 WILLOW MOSS ST
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78232-4546
Practice Address - Country:US
Practice Address - Phone:253-225-7685
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-16
Last Update Date:2019-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program