Provider Demographics
NPI:1811084734
Name:BERWALD, DAVID MORTON (MD)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:MORTON
Last Name:BERWALD
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 1:725 CHAMPEIX
Mailing Address - Street 2:
Mailing Address - City:CREVE COEUR
Mailing Address - State:MO
Mailing Address - Zip Code:63141
Mailing Address - Country:US
Mailing Address - Phone:314-434-7892
Mailing Address - Fax:
Practice Address - Street 1:3478 BRIDGELAND DR
Practice Address - Street 2:
Practice Address - City:BRIDGETON
Practice Address - State:MO
Practice Address - Zip Code:63044-2619
Practice Address - Country:US
Practice Address - Phone:314-739-8200
Practice Address - Fax:314-739-8261
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2012-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO30512208600000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO001010729Medicare ID - Type Unspecified
A13228Medicare UPIN