Provider Demographics
NPI:1316087612
Name:BERTA, THERESA M (MD)
Entity type:Individual
Prefix:DR
First Name:THERESA
Middle Name:M
Last Name:BERTA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 VIA CASITAS
Mailing Address - Street 2:
Mailing Address - City:GREENBRAE
Mailing Address - State:CA
Mailing Address - Zip Code:94904-1901
Mailing Address - Country:US
Mailing Address - Phone:415-464-1771
Mailing Address - Fax:415-464-1158
Practice Address - Street 1:501 VIA CASITAS
Practice Address - Street 2:
Practice Address - City:GREENBRAE
Practice Address - State:CA
Practice Address - Zip Code:94904-1901
Practice Address - Country:US
Practice Address - Phone:415-464-1771
Practice Address - Fax:415-464-1158
Is Sole Proprietor?:No
Enumeration Date:2007-02-07
Last Update Date:2014-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA48830207R00000X, 207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A488300Medicaid
CAF09861Medicare UPIN