Provider Demographics
NPI:1225146673
Name:BERG, IRA JEFFREY (MD)
Entity Type:Individual
Prefix:DR
First Name:IRA
Middle Name:JEFFREY
Last Name:BERG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:160 ROBBINS ST
Mailing Address - Street 2:
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06708-2652
Mailing Address - Country:US
Mailing Address - Phone:203-755-2999
Mailing Address - Fax:203-346-6971
Practice Address - Street 1:160 ROBBINS ST
Practice Address - Street 2:
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06708-2652
Practice Address - Country:US
Practice Address - Phone:203-755-2999
Practice Address - Fax:203-346-6971
Is Sole Proprietor?:No
Enumeration Date:2006-08-27
Last Update Date:2008-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT023706208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT010023706CT01OtherBLUECROSS BLUESHIELD
CT0R0484OtherHEALTHNET
CT023706OtherCONNECTICARE
CTNHP112OtherOXFORD