Healthcare Provider Details

I. General information

NPI: 1124054440
Provider Name (Legal Business Name): VICKI LYNN BERKUS M.D.,PH.D,CEDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/26/2006
Last Update Date: 10/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9 ANZA ST
NEWPORT BEACH CA
92663-4415
US

IV. Provider business mailing address

9 ANZA ST
NEWPORT BEACH CA
92663-4415
US

V. Phone/Fax

Practice location:
  • Phone: 529-561-5531
  • Fax:
Mailing address:
  • Phone: 529-561-5531
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberTM2016-0788
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number20260
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberDR.0049782
License Number StateCO
# 4
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberME106403
License Number StateFL
# 5
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number35083
License Number StateOK
# 6
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number66453
License Number StateMN
# 7
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberG-145096
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: