Provider Demographics
NPI:1992747984
Name:BERMAN, JONATHAN C (MD)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:C
Last Name:BERMAN
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:PO BOX 150
Mailing Address - Street 2:
Mailing Address - City:HOLLY
Mailing Address - State:CO
Mailing Address - Zip Code:81047-0150
Mailing Address - Country:US
Mailing Address - Phone:719-537-0712
Mailing Address - Fax:719-537-6284
Practice Address - Street 1:9191 GRANT ST
Practice Address - Street 2:
Practice Address - City:THORNTON
Practice Address - State:CO
Practice Address - Zip Code:80229-4361
Practice Address - Country:US
Practice Address - Phone:719-537-0712
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2012-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO29754207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01297548Medicaid
CO17364Medicare PIN
CO01297548Medicaid