Healthcare Provider Details

I. General information

NPI: 1023164365
Provider Name (Legal Business Name): BLAKE WADE BERMAN D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/27/2007
Last Update Date: 04/18/2020
Certification Date: 04/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16702 VALLEY VIEW AVE
LA MIRADA CA
90638-5824
US

IV. Provider business mailing address

16702 VALLEY VIEW AVE
LA MIRADA CA
90638-5824
US

V. Phone/Fax

Practice location:
  • Phone: 143-675-3907
  • Fax: 714-367-1683
Mailing address:
  • Phone: 714-367-5390
  • Fax: 714-367-1689

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License Number20A8839
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: