Provider Demographics
NPI:1992862163
Name:BERGER, DOUGLAS T (OPTICIAN)
Entity Type:Individual
Prefix:MR
First Name:DOUGLAS
Middle Name:T
Last Name:BERGER
Suffix:
Gender:M
Credentials:OPTICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:160 SHERMAN AVE
Mailing Address - Street 2:
Mailing Address - City:TEANECK
Mailing Address - State:NJ
Mailing Address - Zip Code:07666-4123
Mailing Address - Country:US
Mailing Address - Phone:917-553-7708
Mailing Address - Fax:
Practice Address - Street 1:2169 WHITE PLAINS RD
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10462-1405
Practice Address - Country:US
Practice Address - Phone:718-409-2200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-03
Last Update Date:2011-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYC005104-1156FC0800X, 156FC0801X, 156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
No156FC0800XEye and Vision Services ProvidersTechnician/TechnologistContact Lens
No156FC0801XEye and Vision Services ProvidersTechnician/TechnologistContact Lens Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00960458Medicaid