Provider Demographics
NPI:1174576169
Name:BERTROCHE, JOSEPH MICHAEL (DO,JD)
Entity type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:MICHAEL
Last Name:BERTROCHE
Suffix:
Gender:M
Credentials:DO,JD
Other - Prefix:
Other - First Name:J.
Other - Middle Name:MICHAEL
Other - Last Name:BERTROCHE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DO,JD
Mailing Address - Street 1:4622 PROGRESS DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52807-3426
Mailing Address - Country:US
Mailing Address - Phone:563-742-5800
Mailing Address - Fax:563-742-5810
Practice Address - Street 1:4622 PROGRESS DR
Practice Address - Street 2:SUITE A
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52807-3426
Practice Address - Country:US
Practice Address - Phone:563-742-5800
Practice Address - Fax:563-742-5810
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2017-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA026932084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA05607Medicare ID - Type Unspecified
IA0076539Medicaid
IA05607Medicare ID - Type Unspecified