Provider Demographics
NPI:1295849594
Name:BERSON, DOUGLAS R (MD)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:R
Last Name:BERSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:224 S WOODS MILL RD
Mailing Address - Street 2:SUITE 270 SOUTH
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:63017-3451
Mailing Address - Country:US
Mailing Address - Phone:314-469-5944
Mailing Address - Fax:314-453-9377
Practice Address - Street 1:224 S WOODS MILL RD
Practice Address - Street 2:SUITE 270 SOUTH
Practice Address - City:CHESTERFIELD
Practice Address - State:MO
Practice Address - Zip Code:63017-3451
Practice Address - Country:US
Practice Address - Phone:314-469-5944
Practice Address - Fax:314-453-9377
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MOR1G07207KA0200X
IL207KA0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207KA0200XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyAllergy
Provider Identifiers
StateIdentifier IDID TypeIssuer
241220OtherHEALTHLINK
24698OtherHEALTHCARE USA
0200049OtherUNITED HEALTHCARE
IL048551OtherHEALTH ALLIANCE
24742OtherBLUE CROSS BLUE SHIELD
8635OtherGROUP HEALTH PLAN
1124116001OtherCIGNA HEALTHCARE
IL385050Medicare ID - Type UnspecifiedILLINOIS MEDICARE
8635OtherGROUP HEALTH PLAN