Provider Demographics
NPI:1538135462
Name:BERG, GORDON J (DPM)
Entity Type:Individual
Prefix:DR
First Name:GORDON
Middle Name:J
Last Name:BERG
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26073 UNION TPKE
Mailing Address - Street 2:
Mailing Address - City:GLEN OAKS
Mailing Address - State:NY
Mailing Address - Zip Code:11004
Mailing Address - Country:US
Mailing Address - Phone:718-347-3447
Mailing Address - Fax:718-347-3663
Practice Address - Street 1:26073 UNION TPKE
Practice Address - Street 2:
Practice Address - City:GLEN OAKS
Practice Address - State:NY
Practice Address - Zip Code:11004
Practice Address - Country:US
Practice Address - Phone:718-347-3447
Practice Address - Fax:718-347-3663
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN0024821213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00406042Medicaid
T32203Medicare UPIN
NY98300Medicare ID - Type Unspecified