Provider Demographics
NPI:1578586590
Name:BERKOWITZ, ROBERT LEO (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:LEO
Last Name:BERKOWITZ
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 1:4644 LINCOLN BLVD
Mailing Address - Street 2:111
Mailing Address - City:MARINA DEL REY
Mailing Address - State:CA
Mailing Address - Zip Code:90292
Mailing Address - Country:US
Mailing Address - Phone:310-306-6966
Mailing Address - Fax:310-306-0667
Practice Address - Street 1:4644 LINCOLN BLVD
Practice Address - Street 2:111
Practice Address - City:MARINA DEL REY
Practice Address - State:CA
Practice Address - Zip Code:90292
Practice Address - Country:US
Practice Address - Phone:310-306-6966
Practice Address - Fax:310-306-0667
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA21955207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A219550OtherMEDICAL PPIN #
CA00A219550OtherMEDICAL PPIN #
CAA22845Medicare UPIN