Provider Demographics
NPI:1245213966
Name:BERGAN, TODD K (PA)
Entity Type:Individual
Prefix:MR
First Name:TODD
Middle Name:K
Last Name:BERGAN
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1860 RENZULLI ROAD
Mailing Address - Street 2:
Mailing Address - City:NEW SMYRNA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32168-1726
Mailing Address - Country:US
Mailing Address - Phone:386-663-3064
Mailing Address - Fax:
Practice Address - Street 1:1860 RENZULLI ROAD
Practice Address - Street 2:
Practice Address - City:NEW SMYRNA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32168-1726
Practice Address - Country:US
Practice Address - Phone:386-663-3064
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-28
Last Update Date:2010-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9102600363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL292262200Medicaid
FLQ04955Medicare UPIN
FL292262200Medicaid