Healthcare Provider Details

I. General information

NPI: 1154366508
Provider Name (Legal Business Name): EBENEZER BERKO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2006
Last Update Date: 06/28/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3330 MASONIC DR
ALEXANDRIA LA
71301-3841
US

IV. Provider business mailing address

3330 MASONIC DR
ALEXANDRIA LA
71301-3841
US

V. Phone/Fax

Practice location:
  • Phone: 318-448-6917
  • Fax: 318-448-6866
Mailing address:
  • Phone: 318-448-6917
  • Fax: 318-448-6866

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License NumberMD.204538
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code207RX0202X
TaxonomyMedical Oncology Physician
License Number036104008
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: