Healthcare Provider Details

I. General information

NPI: 1497713648
Provider Name (Legal Business Name): TOD L BERG M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/03/2006
Last Update Date: 09/30/2021
Certification Date: 09/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1467 S HIGHWAY 40
HEBER UT
84032-3522
US

IV. Provider business mailing address

1467 S HIGHWAY 40
HEBER UT
84032-3522
US

V. Phone/Fax

Practice location:
  • Phone: 435-654-6321
  • Fax: 435-654-6364
Mailing address:
  • Phone: 435-654-6321
  • Fax: 435-654-6364

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number264477-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: