Provider Demographics
NPI:1245625300
Name:BERK, JUSTIN LEE (MD)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:LEE
Last Name:BERK
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 1:110 ELM ST
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02903-4626
Mailing Address - Country:US
Mailing Address - Phone:401-443-4992
Mailing Address - Fax:401-537-7241
Practice Address - Street 1:245 CHAPMAN ST STE 100
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02905-4539
Practice Address - Country:US
Practice Address - Phone:401-444-6118
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-05
Last Update Date:2023-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMD16768207RA0401X, 207R00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program