Provider Demographics
NPI:1225032204
Name:BERGER, EVAN R (MD)
Entity type:Individual
Prefix:DR
First Name:EVAN
Middle Name:R
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 1:235 N BELLE MEAD RD
Mailing Address - Street 2:
Mailing Address - City:EAST SETAUKET
Mailing Address - State:NY
Mailing Address - Zip Code:11733-3456
Mailing Address - Country:US
Mailing Address - Phone:631-751-3000
Mailing Address - Fax:631-751-3366
Practice Address - Street 1:235 N BELLE MEAD RD
Practice Address - Street 2:
Practice Address - City:EAST SETAUKET
Practice Address - State:NY
Practice Address - Zip Code:11733-3456
Practice Address - Country:US
Practice Address - Phone:631-751-3000
Practice Address - Fax:631-751-3366
Is Sole Proprietor?:No
Enumeration Date:2005-06-08
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY109138174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00679790Medicaid
NY109138OtherLICENSE
NY109138OtherLICENSE
NY00679790Medicaid
NY950471Medicare PIN