Provider Demographics
NPI:1609924208
Name:ENGEBRETSEN, BERY J (MD)
Entity Type:Individual
Prefix:
First Name:BERY
Middle Name:J
Last Name:ENGEBRETSEN
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 1:3509 E 29TH ST
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50317-4253
Mailing Address - Country:US
Mailing Address - Phone:515-248-1600
Mailing Address - Fax:515-248-1610
Practice Address - Street 1:2353 SE 14TH ST
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50320-1109
Practice Address - Country:US
Practice Address - Phone:515-248-1400
Practice Address - Fax:515-248-1440
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2014-05-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IA17792207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAA03477Medicare UPIN