Provider Demographics
NPI:1659432458
Name:BERGER, SALLY
Entity Type:Individual
Prefix:
First Name:SALLY
Middle Name:
Last Name:BERGER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1921 STONECIPHER BOULEVARD
Mailing Address - Street 2:
Mailing Address - City:ADA
Mailing Address - State:OK
Mailing Address - Zip Code:74820-2847
Mailing Address - Country:US
Mailing Address - Phone:580-421-6262
Mailing Address - Fax:580-421-4515
Practice Address - Street 1:1921 STONECIPHER BOULEVARD
Practice Address - Street 2:
Practice Address - City:ADA
Practice Address - State:OK
Practice Address - Zip Code:74820-2847
Practice Address - Country:US
Practice Address - Phone:580-421-6262
Practice Address - Fax:580-421-4515
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2011-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK17361207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine