Provider Demographics
NPI:1215999784
Name:BERGER, JOHN LEE (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:LEE
Last Name:BERGER
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 1:15-01 BROADWAY
Mailing Address - Street 2:SUITE 20
Mailing Address - City:FAIR LAWN
Mailing Address - State:NJ
Mailing Address - Zip Code:07410-6003
Mailing Address - Country:US
Mailing Address - Phone:201-794-6008
Mailing Address - Fax:201-794-6190
Practice Address - Street 1:15-01 BROADWAY
Practice Address - Street 2:SUITE 20
Practice Address - City:FAIR LAWN
Practice Address - State:NJ
Practice Address - Zip Code:07410-6003
Practice Address - Country:US
Practice Address - Phone:201-794-6008
Practice Address - Fax:201-794-6190
Is Sole Proprietor?:No
Enumeration Date:2006-04-03
Last Update Date:2008-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA038142174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0475801Medicaid
NJBE198335Medicare ID - Type Unspecified
NJD98901Medicare UPIN