Provider Demographics
NPI:1487724290
Name:BERG, MARY A (MD)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:A
Last Name:BERG
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 1:1312 PRENTICE DRIVE
Mailing Address - Street 2:
Mailing Address - City:HEALDSBURG
Mailing Address - State:CA
Mailing Address - Zip Code:95448
Mailing Address - Country:US
Mailing Address - Phone:707-433-3383
Mailing Address - Fax:707-433-7210
Practice Address - Street 1:1312 PRENTICE DRIVE
Practice Address - Street 2:
Practice Address - City:HEALDSBURG
Practice Address - State:CA
Practice Address - Zip Code:95448
Practice Address - Country:US
Practice Address - Phone:707-433-3383
Practice Address - Fax:707-433-7210
Is Sole Proprietor?:No
Enumeration Date:2006-11-09
Last Update Date:2008-10-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG61587207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
E35844Medicare UPIN