MEDICARE: DR. JACKIE BERKOWITZ

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	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	30014268	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	122384615051	OTHER	OH	CARESOURCE

General Provider Information

NPI Number	:	1801224571
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DR. JACKIE BERKOWITZ

Provider Business Mailing Address
First Line	:	955 N HAMILTON RD
Second Line	:
City	:	GAHANNA
State	:	OH
Zip	:	43230-1758
Country	:	US
Telephone Number	:	614-475-9800
Fax Number	:	614-475-4222

Provider Business Practice Location Address
First Line	:	955 N HAMILTON RD
Second Line	:
City	:	GAHANNA
State	:	OH
Zip	:	43230-1758
Country	:	US
Telephone Number	:	614-475-9800
Fax Number	:	614-475-4222

Authorized Official
Title or Position	:	OWNER
Name	:	DR. JACKIE BERKOWITZ
Credential	:	MD
Telephone Number	:	614-475-9800

Provider Enumeration Date	:	10/16/2013
Last Update Date	:	10/16/2013

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Directions to “DR. JACKIE BERKOWITZ ” Practice Location

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