Provider Demographics
NPI:1982015921
Name:BERG, JAMES P (MD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:P
Last Name:BERG
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 1:5300 NORTH ST
Mailing Address - Street 2:
Mailing Address - City:NACOGDOCHES
Mailing Address - State:TX
Mailing Address - Zip Code:75965-1301
Mailing Address - Country:US
Mailing Address - Phone:936-569-8278
Mailing Address - Fax:936-569-0275
Practice Address - Street 1:5300 NORTH ST
Practice Address - Street 2:
Practice Address - City:NACOGDOCHES
Practice Address - State:TX
Practice Address - Zip Code:75965
Practice Address - Country:US
Practice Address - Phone:936-569-8278
Practice Address - Fax:936-569-0275
Is Sole Proprietor?:No
Enumeration Date:2014-05-13
Last Update Date:2018-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TXR5082207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX3826927Medicaid