Provider Demographics
NPI:1639157035
Name:BERTORELLO, MARIA J (DPM)
Entity Type:Individual
Prefix:
First Name:MARIA
Middle Name:J
Last Name:BERTORELLO
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 550227
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77255-0227
Mailing Address - Country:US
Mailing Address - Phone:713-468-3668
Mailing Address - Fax:713-468-3676
Practice Address - Street 1:12727 KIMBERLEY LN
Practice Address - Street 2:SUITE 102
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77024-4047
Practice Address - Country:US
Practice Address - Phone:713-468-3668
Practice Address - Fax:713-468-3676
Is Sole Proprietor?:No
Enumeration Date:2006-01-05
Last Update Date:2010-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1164213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX112217804Medicaid
U025616Medicare UPIN
TX6010900003Medicare NSC
8F6027Medicare PIN