Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223S0112X | Oral and Maxillofacial Surgeon | 24363 | NY |
NPI | 1013925478 |
---|---|
Provider Name | Dr. Ronald Berg |
First Address | Monticello, NY 12701 |
Second Address | Monticello, NY 12701 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 03/08/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
00501533 | (05) | NY |
D92501 | (02) |