Provider Demographics
NPI:1891873477
Name:BERGER, JACK E (MD)
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:E
Last Name:BERGER
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 1:2520 WESTERNESSE RD
Mailing Address - Street 2:
Mailing Address - City:DAVIS
Mailing Address - State:CA
Mailing Address - Zip Code:95616-2941
Mailing Address - Country:US
Mailing Address - Phone:530-758-6942
Mailing Address - Fax:
Practice Address - Street 1:2020 SUTTER PL
Practice Address - Street 2:
Practice Address - City:DAVIS
Practice Address - State:CA
Practice Address - Zip Code:95616-6213
Practice Address - Country:US
Practice Address - Phone:530-750-7210
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2010-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG22731207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA41699Medicare UPIN