Provider Demographics
NPI: | 1710047329 |
---|---|
Name: | BERDING, ROBIN G (OD) |
Entity Type: | Individual |
Prefix: | DR |
First Name: | ROBIN |
Middle Name: | G |
Last Name: | BERDING |
Suffix: | |
Gender: | F |
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: | 8614 WESTWOOD CENTER DR FL 9 |
Mailing Address - Street 2: | |
Mailing Address - City: | VIENNA |
Mailing Address - State: | VA |
Mailing Address - Zip Code: | 22182-2442 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 703-847-8899 |
Mailing Address - Fax: | 571-223-6780 |
Practice Address - Street 1: | 105 GRAND CENTRAL BLVD STE 110 |
Practice Address - Street 2: | |
Practice Address - City: | POOLER |
Practice Address - State: | GA |
Practice Address - Zip Code: | 31322-4148 |
Practice Address - Country: | US |
Practice Address - Phone: | 912-450-9200 |
Practice Address - Fax: | 912-450-9201 |
Is Sole Proprietor?: | Yes |
Enumeration Date: | 2006-12-12 |
Last Update Date: | 2022-12-27 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
GA | 001177 | 152W00000X |
FL | OPC2705 | 152W00000X |
GA | OPT001177 | 152W00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 152W00000X | Eye and Vision Services Providers | Optometrist |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
GA | 52295473 | Other | BLUE CROSS BLUE SHIELD GA |
GA | 00477815A | Medicaid | |
GA | U28358 | Medicare UPIN | |
GA | 52295473 | Other | BLUE CROSS BLUE SHIELD GA |