Provider Demographics
NPI:1154417657
Name:BERKOWITZ, R. LAURENCE (MD)
Entity type:Individual
Prefix:
First Name:R. LAURENCE
Middle Name:
Last Name:BERKOWITZ
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 1:3803 S. BASCOM AVENUE #100
Mailing Address - Street 2:
Mailing Address - City:CAMPBELL
Mailing Address - State:CA
Mailing Address - Zip Code:95008
Mailing Address - Country:US
Mailing Address - Phone:408-559-7177
Mailing Address - Fax:408-559-7199
Practice Address - Street 1:3803 S. BASCOM AVENUE #100
Practice Address - Street 2:
Practice Address - City:CAMPBELL
Practice Address - State:CA
Practice Address - Zip Code:95008
Practice Address - Country:US
Practice Address - Phone:408-559-7177
Practice Address - Fax:408-559-7199
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC36957174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA89027Medicare UPIN