Provider Demographics
NPI:1467454157
Name:BERG, SETH M (OD)
Entity Type:Individual
Prefix:DR
First Name:SETH
Middle Name:M
Last Name:BERG
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1856 N NOB HILL RD
Mailing Address - Street 2:#261
Mailing Address - City:PLANTATION
Mailing Address - State:FL
Mailing Address - Zip Code:33322-6548
Mailing Address - Country:US
Mailing Address - Phone:954-536-8905
Mailing Address - Fax:954-370-4546
Practice Address - Street 1:1856 N NOB HILL RD
Practice Address - Street 2:#261
Practice Address - City:PLANTATION
Practice Address - State:FL
Practice Address - Zip Code:33322-6548
Practice Address - Country:US
Practice Address - Phone:954-536-8905
Practice Address - Fax:954-370-4546
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-11
Last Update Date:2015-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC3084152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL620329900Medicaid
FLK1857Medicare PIN
FLE0212ZMedicare PIN
FLU69593Medicare UPIN