Provider Demographics
NPI:1902828619
Name:BERENSON, JEFFREY ALAN (MD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:ALAN
Last Name:BERENSON
Suffix:
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 1:3536 MENDOCINO AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95403-3634
Mailing Address - Country:US
Mailing Address - Phone:707-575-6049
Mailing Address - Fax:707-937-1061
Practice Address - Street 1:45081 LITTLE LAKE STREET
Practice Address - Street 2:
Practice Address - City:MENDOCINO
Practice Address - State:CA
Practice Address - Zip Code:95460
Practice Address - Country:US
Practice Address - Phone:707-937-1055
Practice Address - Fax:707-937-1061
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2021-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG39574207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G395740OtherBLUE SHIELD
CA1902828619Medicaid
CAP00872335OtherRAILROAD MEDICARE
CA1902828619Medicaid
CA00G395740Medicare PIN
A47859Medicare UPIN