=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649681966
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARK BERKOVIC D.P.M
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/09/2014
-----------------------------------------------------
Last Update Date | 07/05/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1239 WATERVIEW ST
-----------------------------------------------------
City | FAR ROCKAWAY
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11691-1742
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-514-7018
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1239 WATERVIEW ST
-----------------------------------------------------
City | FAR ROCKAWAY
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11691-1742
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213E00000X
-----------------------------------------------------
Taxonomy Name | Podiatrist
-----------------------------------------------------
License Number | 006830
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------