Provider Demographics
NPI:1720070352
Name:BERG, HOWARD LYSLE (MD)
Entity Type:Individual
Prefix:DR
First Name:HOWARD
Middle Name:LYSLE
Last Name:BERG
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 1:13 MEDICAL DR
Mailing Address - Street 2:
Mailing Address - City:AMARILLO
Mailing Address - State:TX
Mailing Address - Zip Code:79106-4121
Mailing Address - Country:US
Mailing Address - Phone:806-358-4531
Mailing Address - Fax:806-359-1723
Practice Address - Street 1:13 MEDICAL DR
Practice Address - Street 2:
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79106-4121
Practice Address - Country:US
Practice Address - Phone:806-358-4531
Practice Address - Fax:806-359-1723
Is Sole Proprietor?:No
Enumeration Date:2005-08-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF7697207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX089689602Medicaid
TX089689602Medicaid
C13384Medicare UPIN