1215196696 NPI number — DR. DEANE SHORE BERSON MD

Table of content: DR. DEANE SHORE BERSON MD (NPI 1215196696)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215196696 NPI number — DR. DEANE SHORE BERSON MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BERSON
Provider First Name:
DEANE
Provider Middle Name:
SHORE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
COHAN
Provider Other First Name:
DEANE
Provider Other Middle Name:
SHORE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1215196696
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/10/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1424 NORTH HANCOCK AVENUE 3 WEST
Provider Second Line Business Mailing Address:
DEANE SHORE BERSON MD
Provider Business Mailing Address City Name:
COLORADO SPRINGS
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80903
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
719-475-9363
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1424 NORTH HANCOCK AVENUE 3 WEST
Provider Second Line Business Practice Location Address:
DEANE SHORE BERSON MD
Provider Business Practice Location Address City Name:
COLORADO SPRINGS
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80903
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
719-475-9363
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/02/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2084P0800X , with the licence number:  19595 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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