Provider Demographics
NPI:1417059718
Name:BERK, GARY ROBERT (MD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:ROBERT
Last Name:BERK
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 1:105 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HERMON
Mailing Address - State:NY
Mailing Address - Zip Code:13652-3100
Mailing Address - Country:US
Mailing Address - Phone:315-347-2191
Mailing Address - Fax:315-347-4493
Practice Address - Street 1:105 MAIN ST
Practice Address - Street 2:
Practice Address - City:HERMON
Practice Address - State:NY
Practice Address - Zip Code:13652-3100
Practice Address - Country:US
Practice Address - Phone:315-347-2191
Practice Address - Fax:315-347-4493
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1671441207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00986576Medicaid
NYB82761Medicare UPIN
NY53192BMedicare ID - Type Unspecified