Provider Demographics
NPI:1992869960
Name:BERGER, MICHAEL L (O D P C)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:L
Last Name:BERGER
Suffix:
Gender:M
Credentials:O D P C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:126 E MARYLAND AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85012-1126
Mailing Address - Country:US
Mailing Address - Phone:602-978-1199
Mailing Address - Fax:623-487-7046
Practice Address - Street 1:6677 W THUNDERBIRD RD # B132
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85306-3713
Practice Address - Country:US
Practice Address - Phone:602-978-1199
Practice Address - Fax:623-487-7046
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-21
Last Update Date:2008-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAZ0340152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ71756Medicare PIN