Provider Demographics
NPI:1366420390
Name:BERTHOTY, DEAN P (MD)
Entity type:Individual
Prefix:
First Name:DEAN
Middle Name:P
Last Name:BERTHOTY
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 1:1 INDEPENDENCE PT STE 202
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29615-4536
Mailing Address - Country:US
Mailing Address - Phone:877-406-2916
Mailing Address - Fax:
Practice Address - Street 1:3186 S MARYLAND PKWY
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89109-2317
Practice Address - Country:US
Practice Address - Phone:702-942-4123
Practice Address - Fax:702-942-4124
Is Sole Proprietor?:No
Enumeration Date:2006-01-09
Last Update Date:2013-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV56562085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
300047405OtherRR MEDICARE
NV200290211Medicaid
NVNV5656OtherBLUE
NV30WCCBF1NMedicare PIN
C95789Medicare UPIN