Provider Demographics
NPI:1487684239
Name:BERMAN, BLAKE M (MD)
Entity Type:Individual
Prefix:DR
First Name:BLAKE
Middle Name:M
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 1:4914 PACIFICO CT
Mailing Address - Street 2:
Mailing Address - City:PALM BEACH GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33418-8994
Mailing Address - Country:US
Mailing Address - Phone:248-310-3603
Mailing Address - Fax:561-622-6399
Practice Address - Street 1:701 W PLYMOUTH AVE
Practice Address - Street 2:
Practice Address - City:DELAND
Practice Address - State:FL
Practice Address - Zip Code:32720-3236
Practice Address - Country:US
Practice Address - Phone:386-943-3160
Practice Address - Fax:317-705-5047
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-04
Last Update Date:2024-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010526612085N0904X, 2085R0202X
FLME974982085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085N0904XAllopathic & Osteopathic PhysiciansRadiologyNuclear Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3056378Medicaid
MI3056387Medicaid
MI3056387Medicaid