Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207X00000X | Orthopaedic Surgeon | 0101057466 | VA |
Y | 207XX0005X | Sports Medicine Orthopaedic Surgeon | 0101057466 | VA |
NPI | 1114926292 |
---|---|
Provider Name | Jeffrey Howard Berg |
First Address | Reston, VA 20190-5896 |
Second Address | Reston, VA 20190-5896 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 20/07/2005 |
Last Update Date | 31/07/2008 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
G67940 | (02) | VA |