Healthcare Provider Details

I. General information

NPI: 1255420485
Provider Name (Legal Business Name): LESLIE ROBERT BERGHASH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/12/2006
Last Update Date: 09/23/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1801 SE HILLMOOR DR SUITE B105
PORT ST LUCIE FL
34952-7545
US

IV. Provider business mailing address

1801 SE HILLMOOR DR SUITE B105
PORT ST LUCIE FL
34952-7545
US

V. Phone/Fax

Practice location:
  • Phone: 772-398-9911
  • Fax: 772-398-4374
Mailing address:
  • Phone: 772-398-9911
  • Fax: 772-398-4374

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YS0123X
TaxonomyFacial Plastic Surgery Physician
License NumberME0052176
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: