Provider Demographics
NPI:1043224850
Name:BERGENSTAL, KARL WILLIAM (PHD)
Entity Type:Individual
Prefix:DR
First Name:KARL
Middle Name:WILLIAM
Last Name:BERGENSTAL
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1601 CARMEN DR
Mailing Address - Street 2:SUITE 111
Mailing Address - City:CAMARILLO
Mailing Address - State:CA
Mailing Address - Zip Code:93010-3105
Mailing Address - Country:US
Mailing Address - Phone:805-987-7006
Mailing Address - Fax:
Practice Address - Street 1:1601 CARMEN DR
Practice Address - Street 2:SUITE 111
Practice Address - City:CAMARILLO
Practice Address - State:CA
Practice Address - Zip Code:93010-3105
Practice Address - Country:US
Practice Address - Phone:805-987-7006
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY7950103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAR31010Medicare UPIN
CACP7950Medicare ID - Type Unspecified