Provider Demographics
NPI:1639319387
Name:BEREDA, DAVID EDWARD (DO)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:EDWARD
Last Name:BEREDA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1512 N GREEN MOUNT RD
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:IL
Mailing Address - Zip Code:62269-2083
Mailing Address - Country:US
Mailing Address - Phone:618-624-5510
Mailing Address - Fax:
Practice Address - Street 1:1034 S BRENTWOOD BLVD STE 530
Practice Address - Street 2:
Practice Address - City:RICHMOND HEIGHTS
Practice Address - State:MO
Practice Address - Zip Code:63117-1271
Practice Address - Country:US
Practice Address - Phone:314-834-6707
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-20
Last Update Date:2023-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036149289207Q00000X
NE828207Q00000X
MO2022045941207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2022045941OtherFAMILY MEDICINE