Provider Demographics
NPI:1003110495
Name:DWIGHT A BERGQUIST MD INC
Entity Type:Organization
Organization Name:DWIGHT A BERGQUIST MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:DWIGHT
Authorized Official - Middle Name:A
Authorized Official - Last Name:BERGQUIST
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:562-804-4428
Mailing Address - Street 1:5230 N. CLARK AVENUE
Mailing Address - Street 2:SUITE 10
Mailing Address - City:LAKEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90712-2649
Mailing Address - Country:US
Mailing Address - Phone:562-804-4428
Mailing Address - Fax:562-867-5264
Practice Address - Street 1:5230 N. CLARK AVENUE
Practice Address - Street 2:SUITE 10
Practice Address - City:LAKEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90712-2649
Practice Address - Country:US
Practice Address - Phone:562-804-4428
Practice Address - Fax:562-867-5264
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-29
Last Update Date:2013-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG387112084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1053407544OtherTYPE 1 NPI
CAA47573Medicare UPIN
CAG38711Medicare PIN