Provider Demographics
NPI:1396209300
Name:BERTHOLD, BRENDAN J (RDMS)
Entity Type:Individual
Prefix:
First Name:BRENDAN
Middle Name:J
Last Name:BERTHOLD
Suffix:
Gender:M
Credentials:RDMS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14791 E 54TH DR
Mailing Address - Street 2:
Mailing Address - City:YUMA
Mailing Address - State:AZ
Mailing Address - Zip Code:85367-9210
Mailing Address - Country:US
Mailing Address - Phone:928-276-5658
Mailing Address - Fax:
Practice Address - Street 1:14791 E 54TH DR
Practice Address - Street 2:
Practice Address - City:YUMA
Practice Address - State:AZ
Practice Address - Zip Code:85367-9210
Practice Address - Country:US
Practice Address - Phone:928-276-5658
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-23
Last Update Date:2019-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1558992471S1302X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2471S1302XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistSonography