Provider Demographics
NPI:1417977786
Name:BERMAN, JACK (MD)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:
Last Name:BERMAN
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 1:1516 COTNER AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90025-3303
Mailing Address - Country:US
Mailing Address - Phone:310-445-2951
Mailing Address - Fax:310-479-1459
Practice Address - Street 1:2428 SANTA MONICA BLVD
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-2045
Practice Address - Country:US
Practice Address - Phone:310-315-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2022-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC333282085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00C333280Medicaid
CA00C333280OtherBLUE SHIELD
CAWC33328DDMedicare PIN
CA00C3332810Medicare PIN
CA00C333283Medicare PIN
CAWC33328CCMedicare PIN
CAA35231Medicare UPIN
CAWC33328WMedicare PIN
CAWC33328FFMedicare PIN
CAWC33328GGMedicare PIN
CAWC33328IIMedicare PIN
CA00C333285Medicare PIN
CAWC33328BBMedicare PIN
CAWC33328HHMedicare PIN
CA00C333280OtherBLUE SHIELD
CA00C333280Medicaid
CA00C333289Medicare PIN
CAWC33328JJMedicare PIN
CAWC33328OMedicare PIN
CA00C3332812Medicare PIN
CAWC33328RMedicare PIN
CA00C3332811Medicare PIN
CA00C333286Medicare PIN
CA00C333288Medicare PIN
CAOOC333281Medicare PIN
CAWC33328AAMedicare PIN