Provider Demographics
NPI:1073527974
Name:BERGSBAKEN, JEFFREY O (MD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:O
Last Name:BERGSBAKEN
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 1:401 9TH AVE NW
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:SD
Mailing Address - Zip Code:57201-1548
Mailing Address - Country:US
Mailing Address - Phone:605-882-7000
Mailing Address - Fax:605-882-7607
Practice Address - Street 1:401 9TH AVE NW
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:SD
Practice Address - Zip Code:57201-1548
Practice Address - Country:US
Practice Address - Phone:605-882-7000
Practice Address - Fax:605-882-7607
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2020-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD4686207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN59F06BEOtherBCBS
MN901487000Medicaid
SD0007246OtherBCBS
SD5700870Medicaid
SD5700870Medicaid
SD0007246OtherBCBS
SD050077116Medicare ID - Type UnspecifiedRAILROAD