Provider Demographics
NPI:1154366508
Name:BERKO, EBENEZER (MD)
Entity type:Individual
Prefix:
First Name:EBENEZER
Middle Name:
Last Name:BERKO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3330 MASONIC DR
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:LA
Mailing Address - Zip Code:71301-3841
Mailing Address - Country:US
Mailing Address - Phone:318-448-6917
Mailing Address - Fax:318-448-6866
Practice Address - Street 1:3330 MASONIC DR
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:LA
Practice Address - Zip Code:71301-3841
Practice Address - Country:US
Practice Address - Phone:318-448-6917
Practice Address - Fax:318-448-6866
Is Sole Proprietor?:No
Enumeration Date:2006-06-19
Last Update Date:2011-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036104008207RX0202X
LAMD.204538207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
No207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILI33591Medicare UPIN
ILK18679Medicare ID - Type Unspecified