Provider Demographics
NPI:1447251715
Name:BERK, LAWRENCE BRUCE (MD)
Entity type:Individual
Prefix:DR
First Name:LAWRENCE
Middle Name:BRUCE
Last Name:BERK
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 102222
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30368-2222
Mailing Address - Country:US
Mailing Address - Phone:239-274-8200
Mailing Address - Fax:
Practice Address - Street 1:1400 N US HIGHWAY 441 STE 540
Practice Address - Street 2:
Practice Address - City:LADY LAKE
Practice Address - State:FL
Practice Address - Zip Code:32159-8987
Practice Address - Country:US
Practice Address - Phone:352-753-9777
Practice Address - Fax:866-446-1888
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2023-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME645972085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL23146OtherBLUE CROSS BLUE SHIELD
FL275622600Medicaid
FL275622600Medicaid