Provider Demographics
NPI:1437444981
Name:BERG, DOUGLAS BENJAMIN (MD)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:BENJAMIN
Last Name:BERG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3050 MACK RD
Mailing Address - Street 2:SUITE 310
Mailing Address - City:FAIRFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45014-5379
Mailing Address - Country:US
Mailing Address - Phone:513-924-8895
Mailing Address - Fax:513-924-8909
Practice Address - Street 1:3050 MACK RD
Practice Address - Street 2:SUITE 310
Practice Address - City:FAIRFIELD
Practice Address - State:OH
Practice Address - Zip Code:45014-5379
Practice Address - Country:US
Practice Address - Phone:513-924-8895
Practice Address - Fax:513-924-8909
Is Sole Proprietor?:No
Enumeration Date:2011-06-13
Last Update Date:2016-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH57013767208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHH447130Medicare PIN