Provider Demographics
NPI:1205863560
Name:BERGWERK, SALLY R (MD)
Entity Type:Individual
Prefix:DR
First Name:SALLY
Middle Name:R
Last Name:BERGWERK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:372 DANBURY RD STE 197
Mailing Address - Street 2:
Mailing Address - City:WILTON
Mailing Address - State:CT
Mailing Address - Zip Code:06897-2523
Mailing Address - Country:US
Mailing Address - Phone:203-276-3366
Mailing Address - Fax:203-276-3367
Practice Address - Street 1:372 DANBURY RD STE 197
Practice Address - Street 2:
Practice Address - City:WILTON
Practice Address - State:CT
Practice Address - Zip Code:06897-2523
Practice Address - Country:US
Practice Address - Phone:203-762-0024
Practice Address - Fax:203-761-8984
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-26
Last Update Date:2022-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT24336207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
B84053Medicare UPIN