Provider Demographics
NPI:1508890021
Name:BERGER, FRED KEITH (MD)
Entity Type:Individual
Prefix:DR
First Name:FRED
Middle Name:KEITH
Last Name:BERGER
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 1:5317 CALLE VIS
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92109-1920
Mailing Address - Country:US
Mailing Address - Phone:619-298-3251
Mailing Address - Fax:858-488-8839
Practice Address - Street 1:5317 CALLE VIS
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92109-1920
Practice Address - Country:US
Practice Address - Phone:619-298-3251
Practice Address - Fax:858-488-8839
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-10
Last Update Date:2021-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG339962084A0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084A0401XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G339960Medicaid
CAA91553Medicare UPIN
CAG33996Medicare ID - Type Unspecified