Provider Demographics
NPI:1629074141
Name:BERTHERMAN, GEORGE D (OD)
Entity Type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:D
Last Name:BERTHERMAN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1466 BROAD ST
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02905-2836
Mailing Address - Country:US
Mailing Address - Phone:401-941-6221
Mailing Address - Fax:401-941-6227
Practice Address - Street 1:1466 BROAD ST
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02905-2836
Practice Address - Country:US
Practice Address - Phone:401-941-6221
Practice Address - Fax:401-941-6227
Is Sole Proprietor?:No
Enumeration Date:2005-06-21
Last Update Date:2008-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIODTG00481152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
RIGB25798Medicaid
RI0308430001Medicare NSC
RIU48774Medicare UPIN