Provider Demographics
NPI:1023230802
Name:BERG, CHRYSTAL SUMMER ROSE (DPM)
Entity type:Individual
Prefix:
First Name:CHRYSTAL
Middle Name:SUMMER ROSE
Last Name:BERG
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1010 N COUNTRY CLUB DR
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85201-3309
Mailing Address - Country:US
Mailing Address - Phone:480-461-2409
Mailing Address - Fax:
Practice Address - Street 1:777 BANNOCK ST
Practice Address - Street 2:MC 0188
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80204-4507
Practice Address - Country:US
Practice Address - Phone:303-436-6131
Practice Address - Fax:303-436-6572
Is Sole Proprietor?:No
Enumeration Date:2007-05-03
Last Update Date:2009-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPOD-663213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist