Provider Demographics
NPI:1942382007
Name:BERG, EMMETT A (DO)
Entity Type:Individual
Prefix:DR
First Name:EMMETT
Middle Name:A
Last Name:BERG
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:15211 VANOWEN ST
Mailing Address - Street 2:SUITE 105
Mailing Address - City:VAN NUYS
Mailing Address - State:CA
Mailing Address - Zip Code:91405-3606
Mailing Address - Country:US
Mailing Address - Phone:818-997-7711
Mailing Address - Fax:818-997-3744
Practice Address - Street 1:15211 VANOWEN ST
Practice Address - Street 2:SUITE 105
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91405-3606
Practice Address - Country:US
Practice Address - Phone:818-997-7711
Practice Address - Fax:818-997-3744
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CA20A4478207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAE08766Medicare UPIN