Provider Demographics
NPI:1285671180
Name:BERSTOCK, AVI (PA)
Entity type:Individual
Prefix:
First Name:AVI
Middle Name:
Last Name:BERSTOCK
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1214 S CURLEY ST
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21224-4859
Mailing Address - Country:US
Mailing Address - Phone:410-342-5455
Mailing Address - Fax:
Practice Address - Street 1:5601 LOCH RAVEN BLVD
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21239-2905
Practice Address - Country:US
Practice Address - Phone:410-532-4040
Practice Address - Fax:410-532-4962
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2024-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0002268363A00000X
VA0110005739363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
P11951Medicare UPIN
MD39MMMedicare ID - Type Unspecified