Provider Demographics
NPI:1184009771
Name:BERGMAN, KEVIN PATRICK (DPT)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:PATRICK
Last Name:BERGMAN
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1019 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MANTECA
Mailing Address - State:CA
Mailing Address - Zip Code:95337-5703
Mailing Address - Country:US
Mailing Address - Phone:209-624-1002
Mailing Address - Fax:209-222-6182
Practice Address - Street 1:1019 S MAIN ST
Practice Address - Street 2:
Practice Address - City:MANTECA
Practice Address - State:CA
Practice Address - Zip Code:95337-5703
Practice Address - Country:US
Practice Address - Phone:209-624-1002
Practice Address - Fax:209-222-6182
Is Sole Proprietor?:No
Enumeration Date:2015-07-23
Last Update Date:2020-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA295892225100000X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist