Provider Demographics
NPI:1194392241
Name:BERGDOLT, CHARLES KENNETH (DO)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:KENNETH
Last Name:BERGDOLT
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4755 PASTURE RD
Mailing Address - Street 2:
Mailing Address - City:FALLON
Mailing Address - State:NV
Mailing Address - Zip Code:89406-3491
Mailing Address - Country:US
Mailing Address - Phone:334-224-8053
Mailing Address - Fax:
Practice Address - Street 1:4755 PASTURE RD
Practice Address - Street 2:
Practice Address - City:FALLON
Practice Address - State:NV
Practice Address - Zip Code:89406-3491
Practice Address - Country:US
Practice Address - Phone:904-542-7300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-08
Last Update Date:2023-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL8288488207Q00000X
IDO-17342083A0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083A0100XAllopathic & Osteopathic PhysiciansPreventive MedicineAerospace Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine