Provider Demographics
NPI:1629047659
Name:BERG, STEPHANIE M (MD)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:M
Last Name:BERG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4280 MAIN ST
Mailing Address - Street 2:STE 200
Mailing Address - City:FRISCO
Mailing Address - State:TX
Mailing Address - Zip Code:75033-3080
Mailing Address - Country:US
Mailing Address - Phone:972-464-2510
Mailing Address - Fax:214-705-1379
Practice Address - Street 1:4280 MAIN ST
Practice Address - Street 2:STE 200
Practice Address - City:FRISCO
Practice Address - State:TX
Practice Address - Zip Code:75033-3075
Practice Address - Country:US
Practice Address - Phone:972-464-2510
Practice Address - Fax:214-705-1379
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2022-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK22391207R00000X
FL858554342083B0002X
TXN0643207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No2083B0002XAllopathic & Osteopathic PhysiciansPreventive MedicineObesity Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX198848702Medicaid
TX198848703Medicaid
TX8L5102Medicare PIN
TX8L5101Medicare PIN
TX8L5339Medicare PIN
24R600670Medicare PIN
TX198848701Medicaid
TXTXB121855Medicare PIN
TX198848705Medicaid