Provider Demographics
NPI:1487852463
Name:BERKOWITZ, IRA CHARLES (MD)
Entity Type:Individual
Prefix:DR
First Name:IRA
Middle Name:CHARLES
Last Name:BERKOWITZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2019 GALISTEO ST
Mailing Address - Street 2:J-1
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-2143
Mailing Address - Country:US
Mailing Address - Phone:505-820-0446
Mailing Address - Fax:505-820-6142
Practice Address - Street 1:2019 GALISTEO ST
Practice Address - Street 2:J-1
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-2143
Practice Address - Country:US
Practice Address - Phone:505-820-0446
Practice Address - Fax:505-820-6142
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-11
Last Update Date:2014-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM82-167207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM18689Medicaid
NM342411800Medicare PIN
NMD35510Medicare UPIN