Provider Demographics
NPI:1396840583
Name:BERG, LAVONNE A (MD)
Entity Type:Individual
Prefix:
First Name:LAVONNE
Middle Name:A
Last Name:BERG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 N OAKLAND AVE
Mailing Address - Street 2:
Mailing Address - City:BOLIVAR
Mailing Address - State:MO
Mailing Address - Zip Code:65613-3011
Mailing Address - Country:US
Mailing Address - Phone:417-328-6738
Mailing Address - Fax:417-328-6776
Practice Address - Street 1:1551 N. OAKLAND
Practice Address - Street 2:
Practice Address - City:BOLIVAR
Practice Address - State:MO
Practice Address - Zip Code:65613
Practice Address - Country:US
Practice Address - Phone:417-328-6738
Practice Address - Fax:417-328-6776
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2011-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOMD114202207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO029013888Medicare PIN
MOF63555Medicare UPIN