Provider Demographics
NPI:1164420881
Name:BERGAMO, GREGORY JOHN (DPM)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:JOHN
Last Name:BERGAMO
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:NY
Mailing Address - Zip Code:10940-5119
Mailing Address - Country:US
Mailing Address - Phone:845-343-6050
Mailing Address - Fax:845-343-5488
Practice Address - Street 1:110 E MAIN ST
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:NY
Practice Address - Zip Code:10940-5119
Practice Address - Country:US
Practice Address - Phone:845-343-6050
Practice Address - Fax:845-343-5488
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-07
Last Update Date:2012-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYNOO5115213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY6697590001Medicare NSC