Provider Demographics
NPI:1235211798
Name:BERGERON, EDMOND X III (MP)
Entity Type:Individual
Prefix:
First Name:EDMOND
Middle Name:X
Last Name:BERGERON
Suffix:III
Gender:M
Credentials:MP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:806 JEFFERSON TER
Mailing Address - Street 2:
Mailing Address - City:NEW IBERIA
Mailing Address - State:LA
Mailing Address - Zip Code:70560-5727
Mailing Address - Country:US
Mailing Address - Phone:337-365-4945
Mailing Address - Fax:337-376-6860
Practice Address - Street 1:806 JEFFERSON TER
Practice Address - Street 2:
Practice Address - City:NEW IBERIA
Practice Address - State:LA
Practice Address - Zip Code:70560-5727
Practice Address - Country:US
Practice Address - Phone:337-365-4945
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-20
Last Update Date:2019-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA606MP103T00000X, 103TP0016X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TP0016XBehavioral Health & Social Service ProvidersPsychologistPrescribing (Medical)
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1660841Medicaid
LA5S350Medicare ID - Type Unspecified