Provider Demographics
NPI:1871540252
Name:BERT, JEFFREY K (MD)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:K
Last Name:BERT
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 1:2699 N 17TH ST
Mailing Address - Street 2:
Mailing Address - City:COOS BAY
Mailing Address - State:OR
Mailing Address - Zip Code:97420-2134
Mailing Address - Country:US
Mailing Address - Phone:541-266-3600
Mailing Address - Fax:541-269-0708
Practice Address - Street 1:2699 N 17TH ST
Practice Address - Street 2:
Practice Address - City:COOS BAY
Practice Address - State:OR
Practice Address - Zip Code:97420-2134
Practice Address - Country:US
Practice Address - Phone:541-266-3600
Practice Address - Fax:541-269-0708
Is Sole Proprietor?:No
Enumeration Date:2006-05-30
Last Update Date:2010-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD09764207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
C105001OtherPACIFIC SOURCE
OR240218Medicaid
200025535OtherRAILROAD MEDICARE
050922009OtherBLUE CROSS
97420A010OtherTRICARE
050922009OtherBLUE CROSS
200025535OtherRAILROAD MEDICARE