Provider Demographics
NPI:1164740544
Name:BERGMAN, MARY LEE (AP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:LEE
Last Name:BERGMAN
Suffix:
Gender:F
Credentials:AP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3079 E. COMMERCIAL BLVD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33308-4311
Mailing Address - Country:US
Mailing Address - Phone:954-551-1243
Mailing Address - Fax:
Practice Address - Street 1:3079 E. COMMERCIAL BLVD
Practice Address - Street 2:SUITE 201
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33308-4311
Practice Address - Country:US
Practice Address - Phone:954-551-1243
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-11
Last Update Date:2010-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL404171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist