Provider Demographics
NPI:1669568309
Name:BERTMAN, GARY M (MD)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:M
Last Name:BERTMAN
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 1:157 MONTAUK AVE
Mailing Address - Street 2:
Mailing Address - City:NEW LONDON
Mailing Address - State:CT
Mailing Address - Zip Code:06320-4842
Mailing Address - Country:US
Mailing Address - Phone:860-437-0333
Mailing Address - Fax:860-439-1330
Practice Address - Street 1:157 MONTAUK AVE
Practice Address - Street 2:
Practice Address - City:NEW LONDON
Practice Address - State:CT
Practice Address - Zip Code:06320-4842
Practice Address - Country:US
Practice Address - Phone:860-437-0333
Practice Address - Fax:860-439-1330
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2010-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT028661207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001286617Medicaid
CT001286617Medicaid
CTB38284Medicare UPIN