Provider Demographics
NPI:1598033177
Name:BERKELEY MEDICAL ASSOCIATE, PC
Entity Type:Organization
Organization Name:BERKELEY MEDICAL ASSOCIATE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAGDISH
Authorized Official - Middle Name:K
Authorized Official - Last Name:GUPTA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:917-941-2886
Mailing Address - Street 1:PO BOX 270
Mailing Address - Street 2:
Mailing Address - City:MASSAPEQUA PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11762-0270
Mailing Address - Country:US
Mailing Address - Phone:631-264-2035
Mailing Address - Fax:631-264-1418
Practice Address - Street 1:207 BERKELEY PL
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11217-3801
Practice Address - Country:US
Practice Address - Phone:347-529-6322
Practice Address - Fax:718-638-4033
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-09
Last Update Date:2011-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY123886207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty