Provider Demographics
NPI:1164641387
Name:BERGESON, DEREK SCOTT (MD)
Entity Type:Individual
Prefix:DR
First Name:DEREK
Middle Name:SCOTT
Last Name:BERGESON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:1055 N 500 W
Mailing Address - Street 2:ATTN CREDENTIALING
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604
Mailing Address - Country:US
Mailing Address - Phone:801-354-8225
Mailing Address - Fax:801-418-0941
Practice Address - Street 1:1055 N 500 W
Practice Address - Street 2:ATTN CREDENTIALING
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-8460
Practice Address - Country:US
Practice Address - Phone:801-354-8225
Practice Address - Fax:801-418-0941
Is Sole Proprietor?:No
Enumeration Date:2007-04-25
Last Update Date:2022-06-30
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CO455562085R0202X
UT12767278-12052085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
I02451Medicare UPIN