Provider Demographics
NPI:1578053526
Name:BERSHAD, DEREK (PT, DPT)
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:
Last Name:BERSHAD
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18 HAMILTON PL
Mailing Address - Street 2:
Mailing Address - City:LAKE GROVE
Mailing Address - State:NY
Mailing Address - Zip Code:11755-1915
Mailing Address - Country:US
Mailing Address - Phone:631-780-5550
Mailing Address - Fax:631-285-2124
Practice Address - Street 1:2848 MIDDLE COUNTRY RD
Practice Address - Street 2:
Practice Address - City:LAKE GROVE
Practice Address - State:NY
Practice Address - Zip Code:11755-2104
Practice Address - Country:US
Practice Address - Phone:631-780-5550
Practice Address - Fax:631-285-2124
Is Sole Proprietor?:No
Enumeration Date:2018-05-15
Last Update Date:2018-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY042950-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist