Basic Information
| Provider Information | |||||||||
| NPI: | 1245288471 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BERLIN | ||||||||
| FirstName: | DEBBIE | ||||||||
| MiddleName: | A. | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11945 SAN JOSE BLVD | ||||||||
| Address2: | BLDG 300 | ||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322231627 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9043961725 | ||||||||
| FaxNumber: | 9043991717 | ||||||||
| Practice Location | |||||||||
| Address1: | 1555 KINGSLEY AVE | ||||||||
| Address2: | SUITE 503 | ||||||||
| City: | ORANGE PARK | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320739207 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9042785088 | ||||||||
| FaxNumber: | 9042644910 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/04/2006 | ||||||||
| LastUpdateDate: | 06/23/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | ME90493 | FL | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | P00146174 | 01 | FL | RAILROAD MEDICARE | OTHER | 274974200 | 05 | FL | MEDICAID | 294216 | 01 | AVMED | OTHER | 7431565 | 01 | AETNA | OTHER | 50705 | 01 | BCBS FL | OTHER | 5953872 | 01 | CIGNA | OTHER |