Healthcare Provider Details

I. General information

NPI: 1205213337
Provider Name (Legal Business Name): DOMINICK ANTHONY SHAO-BERKERY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: DOMINICK ANTHONY BERKERY

II. Dates (important events)

Enumeration Date: 04/27/2015
Last Update Date: 03/29/2023
Certification Date: 03/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

66 SHERIDAN AVE
WALDWICK NJ
07463-2210
US

IV. Provider business mailing address

622 WEST 168TH STREET PH 505, 5TH FLOOR
NEW YORK NY
10032-3720
US

V. Phone/Fax

Practice location:
  • Phone: 415-999-6543
  • Fax:
Mailing address:
  • Phone: 415-999-6543
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number598181
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number95000377
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: