Healthcare Provider Details

I. General information

NPI: 1376541540
Provider Name (Legal Business Name): GREGG JONATHAN BERDY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2005
Last Update Date: 03/30/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12990 MANCHESTER RD SUITE 200
SAINT LOUIS MO
63131-1860
US

IV. Provider business mailing address

12990 MANCHESTER RD SUITE 200
SAINT LOUIS MO
63131-1860
US

V. Phone/Fax

Practice location:
  • Phone: 314-966-5000
  • Fax: 314-909-6666
Mailing address:
  • Phone: 314-966-5000
  • Fax: 314-909-6666

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberR1E17
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: