Provider Demographics
NPI:1134358203
Name:BERTINI, MARIA THERESA (DO)
Entity type:Individual
Prefix:DR
First Name:MARIA
Middle Name:THERESA
Last Name:BERTINI
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:MARIA
Other - Middle Name:THERESA
Other - Last Name:GAVIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:346 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:NY
Mailing Address - Zip Code:13790-2580
Mailing Address - Country:US
Mailing Address - Phone:607-729-8156
Mailing Address - Fax:607-729-3982
Practice Address - Street 1:4417 VESTAL PARKWAY EAST
Practice Address - Street 2:
Practice Address - City:VESTAL
Practice Address - State:NY
Practice Address - Zip Code:13850-3556
Practice Address - Country:US
Practice Address - Phone:607-770-7365
Practice Address - Fax:607-729-5882
Is Sole Proprietor?:No
Enumeration Date:2009-07-09
Last Update Date:2012-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY264159207Q00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program