Provider Demographics
NPI:1821192501
Name:VAN DEN BERG, EGERTON K JR (MD)
Entity Type:Individual
Prefix:
First Name:EGERTON
Middle Name:K
Last Name:VAN DEN BERG
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2320 N ORANGE AVE
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32804-5506
Mailing Address - Country:US
Mailing Address - Phone:407-896-0054
Mailing Address - Fax:407-898-4463
Practice Address - Street 1:2320 N ORANGE AVE
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32804-5506
Practice Address - Country:US
Practice Address - Phone:407-896-0054
Practice Address - Fax:407-898-4463
Is Sole Proprietor?:No
Enumeration Date:2006-09-12
Last Update Date:2019-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX117611207R00000X
VA117611207RI0011X
FLME54054207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL103555800Medicaid
B27236Medicare UPIN