Provider Demographics
NPI:1528050408
Name:BERENS, STEPHEN C (MD)
Entity type:Individual
Prefix:MR
First Name:STEPHEN
Middle Name:C
Last Name:BERENS
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 1:1301 20TH ST. #590
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90404
Mailing Address - Country:US
Mailing Address - Phone:310-828-4633
Mailing Address - Fax:818-784-5639
Practice Address - Street 1:1301 20TH ST #590
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404
Practice Address - Country:US
Practice Address - Phone:310-828-4633
Practice Address - Fax:818-784-5639
Is Sole Proprietor?:No
Enumeration Date:2005-08-17
Last Update Date:2011-06-01
Deactivation Date:2006-03-23
Deactivation Code:
Reactivation Date:2006-03-28
Provider Licenses
StateLicense IDTaxonomies
CAA22556207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA23140Medicare UPIN