Healthcare Provider Details

I. General information

NPI: 1942382007
Provider Name (Legal Business Name): EMMETT A. BERG D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/19/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15211 VANOWEN ST SUITE 105
VAN NUYS CA
91405-3606
US

IV. Provider business mailing address

15211 VANOWEN ST SUITE 105
VAN NUYS CA
91405-3606
US

V. Phone/Fax

Practice location:
  • Phone: 818-997-7711
  • Fax: 818-997-3744
Mailing address:
  • Phone: 818-997-7711
  • Fax: 818-997-3744

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number20A4478
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: