ETHAN PATRICK BERG DO Medical Doctor License verification

Business Entity

CANCELLED

License Type

Medical Doctor

Description

TEMPORARY MEDICAL PERMIT

License Number

125071205

License Status

CANCELLED

Business

Title

First Name

ETHAN

Middle

PATRICK

Last Name

BERG

Business Name

ETHAN PATRICK BERG DO

Original Issue Date

06/26/2017

Effective Date

06/26/2017

Expiration Date

06/26/2020

City

SPRINGFIELD

State

Zip

62701

County

SANGAMON

Specialty/Qualifier

Family Medicine

Ever Disciplined

LastModifiedDate

05/15/2017