Provider Demographics
NPI:1225021009
Name:JOHN, BERTHA A (MD)
Entity Type:Individual
Prefix:DR
First Name:BERTHA
Middle Name:A
Last Name:JOHN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:230 E 71ST ST
Mailing Address - Street 2:3F
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10021-5130
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:212 E 106TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10029-4007
Practice Address - Country:US
Practice Address - Phone:212-360-2600
Practice Address - Fax:212-360-2618
Is Sole Proprietor?:No
Enumeration Date:2005-08-26
Last Update Date:2012-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY199399208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00355151Medicaid
NYG34496Medicare UPIN
NY33-1844Medicare ID - Type Unspecified