Provider Demographics
NPI:1447244371
Name:BERG, JONATHAN BENJAMIN (DO)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:BENJAMIN
Last Name:BERG
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 CAREY RD
Mailing Address - Street 2:
Mailing Address - City:QUEENSBURY
Mailing Address - State:NY
Mailing Address - Zip Code:12804-7880
Mailing Address - Country:US
Mailing Address - Phone:518-761-0300
Mailing Address - Fax:518-480-0108
Practice Address - Street 1:100 PARK ST
Practice Address - Street 2:
Practice Address - City:GLENS FALLS
Practice Address - State:NY
Practice Address - Zip Code:12801-4413
Practice Address - Country:US
Practice Address - Phone:518-761-0300
Practice Address - Fax:518-792-8231
Is Sole Proprietor?:No
Enumeration Date:2005-09-07
Last Update Date:2010-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY228061-1207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYRB6784Medicare PIN
NY331852Medicare Oscar/Certification