Provider Demographics
NPI:1396833000
Name:BERTA, S LOUIS (OD)
Entity Type:Individual
Prefix:
First Name:S
Middle Name:LOUIS
Last Name:BERTA
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:STEVEN
Other - Middle Name:LOUIS
Other - Last Name:BERTA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OD
Mailing Address - Street 1:15171 BURCHAM RD
Mailing Address - Street 2:
Mailing Address - City:LOGAN
Mailing Address - State:OH
Mailing Address - Zip Code:43138-8995
Mailing Address - Country:US
Mailing Address - Phone:740-385-6545
Mailing Address - Fax:
Practice Address - Street 1:15171 BURCHAM RD
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:OH
Practice Address - Zip Code:43138-8995
Practice Address - Country:US
Practice Address - Phone:740-385-6545
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2458763152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist