Provider Demographics
NPI:1952303596
Name:BERZINCH, IVETA (MD, PC)
Entity Type:Individual
Prefix:
First Name:IVETA
Middle Name:
Last Name:BERZINCH
Suffix:
Gender:F
Credentials:MD, PC
Other - Prefix:
Other - First Name:IVETA
Other - Middle Name:
Other - Last Name:BERZINCH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MC, PC
Mailing Address - Street 1:1704 BOULEVARD SQUARE, SUITE B
Mailing Address - Street 2:
Mailing Address - City:WAYCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:31501
Mailing Address - Country:US
Mailing Address - Phone:912-285-8866
Mailing Address - Fax:912-285-8881
Practice Address - Street 1:1704 BOULEVARD SQ STE B
Practice Address - Street 2:
Practice Address - City:WAYCROSS
Practice Address - State:GA
Practice Address - Zip Code:31501-8023
Practice Address - Country:US
Practice Address - Phone:912-285-8866
Practice Address - Fax:912-285-8881
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-12
Last Update Date:2013-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA043873208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000781954AMedicaid