Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 156FC0800X | Contact Lens | C005104-1 | NY |
N | 156FC0801X | Contact Lens Fitter | C005104-1 | NY |
Y | 156FX1800X | Optician | C005104-1 | NY |
NPI | 1992862163 |
---|---|
Provider Name | Mr. Douglas T Berger |
First Address | Teaneck, NJ 07666-4123 |
Second Address | Bronx, NY 10462-1405 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 03/01/2007 |
Last Update Date | 21/09/2011 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
00960458 | (05) | NY |