Provider Demographics
NPI:1386729721
Name:BERGER, GARY D (OD)
Entity type:Individual
Prefix:DR
First Name:GARY
Middle Name:D
Last Name:BERGER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1663 E TALUS WAY
Mailing Address - Street 2:
Mailing Address - City:ST GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84790-3901
Mailing Address - Country:US
Mailing Address - Phone:949-235-2476
Mailing Address - Fax:
Practice Address - Street 1:10 E 1300 S
Practice Address - Street 2:
Practice Address - City:RICHFIELD
Practice Address - State:UT
Practice Address - Zip Code:84701
Practice Address - Country:US
Practice Address - Phone:435-893-8478
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-26
Last Update Date:2020-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11462152W00000X
NV514152W00000X
UT11209657-9934152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU82844Medicare UPIN