Provider Demographics
NPI:1639133036
Name:BERGER, LESLY (MD)
Entity Type:Individual
Prefix:
First Name:LESLY
Middle Name:
Last Name:BERGER
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 1:9011 CHEVROLET DR
Mailing Address - Street 2:SUITES 1-6
Mailing Address - City:ELLICOTT CITY
Mailing Address - State:MD
Mailing Address - Zip Code:21042-4024
Mailing Address - Country:US
Mailing Address - Phone:410-465-7550
Mailing Address - Fax:410-465-7085
Practice Address - Street 1:9011 CHEVROLET DR
Practice Address - Street 2:SUITES 1-6
Practice Address - City:ELLICOTT CITY
Practice Address - State:MD
Practice Address - Zip Code:21042-4024
Practice Address - Country:US
Practice Address - Phone:410-465-7550
Practice Address - Fax:410-465-7085
Is Sole Proprietor?:No
Enumeration Date:2006-04-13
Last Update Date:2012-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0054406208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD492600500Medicaid