Provider Demographics
NPI:1285651141
Name:BERBAUM, MARK WILLIAM (MD)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:WILLIAM
Last Name:BERBAUM
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 1:4527 EVERHARD RD NW
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44718
Mailing Address - Country:US
Mailing Address - Phone:330-966-3111
Mailing Address - Fax:330-966-1416
Practice Address - Street 1:4527 EVERHARD RD NW
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44718
Practice Address - Country:US
Practice Address - Phone:330-966-3111
Practice Address - Fax:330-966-1416
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-16
Last Update Date:2013-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35056279B207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
070008885OtherRAILROAD MEDICARE
34180382300OtherWORKERS COMPENSATION
000000139234OtherANTHEM BCBS
000000139234OtherANTHEM BCBS
34180382300OtherWORKERS COMPENSATION