Provider Demographics
NPI:1013935873
Name:BERKOVICH, LAZAR
Entity Type:Individual
Prefix:
First Name:LAZAR
Middle Name:
Last Name:BERKOVICH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30500 NORTHWESTERN HWY STE 316B
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48334-3159
Mailing Address - Country:US
Mailing Address - Phone:248-258-6842
Mailing Address - Fax:
Practice Address - Street 1:30500 NORTHWESTERN HWY STE 316B
Practice Address - Street 2:
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48334-3159
Practice Address - Country:US
Practice Address - Phone:248-258-6842
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MILB008193111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4237430Medicaid
MI2436327OtherAETNA
MIU81592Medicare UPIN
MION16320Medicare ID - Type Unspecified