Healthcare Provider Details

I. General information

NPI: 1134358203
Provider Name (Legal Business Name): MARIA THERESA BERTINI D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARIA THERESA GAVIN DO

II. Dates (important events)

Enumeration Date: 07/09/2009
Last Update Date: 09/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4417 VESTAL PARKWAY EAST
VESTAL NY
13850-3556
US

IV. Provider business mailing address

346 GRAND AVE
JOHNSON CITY NY
13790-2580
US

V. Phone/Fax

Practice location:
  • Phone: 607-770-7365
  • Fax: 607-729-5882
Mailing address:
  • Phone: 607-729-8156
  • Fax: 607-729-3982

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number264159
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: