Provider Demographics
NPI:1629247820
Name:BERG, KEVIN CRAIG (OD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:CRAIG
Last Name:BERG
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 1:1350 S SEWARD MERIDIAN PKWY
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654-8332
Mailing Address - Country:US
Mailing Address - Phone:907-376-0835
Mailing Address - Fax:907-376-0843
Practice Address - Street 1:1350 S SEWARD MERIDIAN PKWY
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-8332
Practice Address - Country:US
Practice Address - Phone:907-376-0835
Practice Address - Fax:907-376-0843
Is Sole Proprietor?:No
Enumeration Date:2008-02-21
Last Update Date:2008-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK104152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKOD1144Medicaid