MEDICARE: DR. ROBERT NGO BERTHOLD M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084P0800X	Psychiatry Physician	A85746	CA

General Provider Information

NPI Number	:	1114003787
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ROBERT NGO BERTHOLD M.D.

Provider Business Mailing Address
First Line	:	1136 MAGNOLIA AVE
Second Line	:
City	:	GARDENA
State	:	CA
Zip	:	90247-4305
Country	:	US
Telephone Number	:	310-800-7017
Fax Number	:

Provider Business Practice Location Address
First Line	:	14623 HAWTHORNE BLVD
Second Line	:	SUITE 400
City	:	LAWNDALE
State	:	CA
Zip	:	90260-1581
Country	:	US
Telephone Number	:	310-970-5023
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/27/2006
Last Update Date	:	02/17/2011

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