Provider Demographics
NPI:1073148235
Name:BERGUM, JAMES DOUGLAS (CCP)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:DOUGLAS
Last Name:BERGUM
Suffix:
Gender:M
Credentials:CCP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:144 HOLM RD SPC 31
Mailing Address - Street 2:
Mailing Address - City:WATSONVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95076-2427
Mailing Address - Country:US
Mailing Address - Phone:831-277-0810
Mailing Address - Fax:
Practice Address - Street 1:1555 SOQUEL DR
Practice Address - Street 2:
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95065-1794
Practice Address - Country:US
Practice Address - Phone:855-489-4580
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-09
Last Update Date:2020-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
049011242T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes242T00000XTechnologists, Technicians & Other Technical Service ProvidersPerfusionistGroup - Single Specialty