Provider Demographics
NPI:1205818804
Name:BERGER, GARY LEE (MD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:LEE
Last Name:BERGER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:2234 COLONIAL BLVD
Mailing Address - Street 2:MANAGED CARE DEPARTMENT
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-1412
Mailing Address - Country:US
Mailing Address - Phone:239-931-7342
Mailing Address - Fax:239-931-7385
Practice Address - Street 1:2400 HARBOR BLVD
Practice Address - Street 2:SUITE 21
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33952-5052
Practice Address - Country:US
Practice Address - Phone:941-625-6992
Practice Address - Fax:941-625-7238
Is Sole Proprietor?:No
Enumeration Date:2005-11-18
Last Update Date:2016-04-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME0030516208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL25028OtherBCBS PROVIDER #
FL217124OtherAVMED
FL47450OtherBCBS OF FL
FL002736800Medicaid
FL8707000OtherCIGNA PROVIDER #
FL8707000OtherCIGNA
FL1192904OtherWELLCARE
FL8707000OtherCIGNA
FL25028ZMedicare PIN