Provider Demographics
NPI:1225123243
Name:BERG, MIJA (NP)
Entity Type:Individual
Prefix:
First Name:MIJA
Middle Name:
Last Name:BERG
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1601 FRUITVALE AVE
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94601-2322
Mailing Address - Country:US
Mailing Address - Phone:510-535-4000
Mailing Address - Fax:510-535-4128
Practice Address - Street 1:243 GEORGIA STREET
Practice Address - Street 2:SUITE B
Practice Address - City:VALLEJO
Practice Address - State:CA
Practice Address - Zip Code:94590
Practice Address - Country:US
Practice Address - Phone:707-556-8100
Practice Address - Fax:707-556-8107
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2007-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP479996363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAFHC70543GMedicaid
CAHAP70543GOtherFPACT
CA55-1915OtherFQHC MEDICARE PART A
CAZZZ23222ZOtherFQHC MEDICARE PART B