Provider Demographics
NPI:1073518130
Name:BERGMAN, LAWRENCE RUSSELL (MD)
Entity Type:Individual
Prefix:DR
First Name:LAWRENCE
Middle Name:RUSSELL
Last Name:BERGMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10115 W FOREST HILL BLVD
Mailing Address - Street 2:STE 303
Mailing Address - City:WELLINGTON
Mailing Address - State:FL
Mailing Address - Zip Code:33414-3102
Mailing Address - Country:US
Mailing Address - Phone:561-798-5565
Mailing Address - Fax:561-798-9756
Practice Address - Street 1:10115 W FOREST HILL BLVD
Practice Address - Street 2:STE 303
Practice Address - City:WELLINGTON
Practice Address - State:FL
Practice Address - Zip Code:33414-3102
Practice Address - Country:US
Practice Address - Phone:561-798-5565
Practice Address - Fax:561-798-9756
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-16
Last Update Date:2011-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME561642080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL003224800Medicaid
FLE91787Medicare UPIN