1003177593 NPI number — DANIELLE KUSSEROW BERSABE M.D.

Table of content: DANIELLE KUSSEROW BERSABE M.D. (NPI 1003177593)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003177593 NPI number — DANIELLE KUSSEROW BERSABE M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BERSABE
Provider First Name:
DANIELLE
Provider Middle Name:
KUSSEROW
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1003177593
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/19/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2200 BERQUIST DR
Provider Second Line Business Mailing Address:
INTERNAL MEDICINE CLINIC
Provider Business Mailing Address City Name:
LACKLAND AFB
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78233
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
920 CEDAR LAKE RD STE R
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BILOXI
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39532-2107
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
228-207-0260
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/31/2012

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: 207R00000X , with the licence number:  26567 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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