Healthcare Provider Details

I. General information

NPI: 1013970664
Provider Name (Legal Business Name): MICHAEL P BERG MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/06/2006
Last Update Date: 07/16/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

421 WEST RIVERSIDE #280
SPOKANE WA
99201
US

IV. Provider business mailing address

421 WEST RIVERSIDE #280
SPOKANE WA
99201
US

V. Phone/Fax

Practice location:
  • Phone: 509-838-2757
  • Fax: 509-838-2184
Mailing address:
  • Phone: 509-838-2757
  • Fax: 509-838-2184

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number13399
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: