Provider Demographics
NPI:1275548018
Name:BERGQUIST, SHARON HORESH (MD)
Entity Type:Individual
Prefix:DR
First Name:SHARON
Middle Name:HORESH
Last Name:BERGQUIST
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2801 N DECATUR RD
Mailing Address - Street 2:SUITE 295
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30033-5949
Mailing Address - Country:US
Mailing Address - Phone:404-778-6124
Mailing Address - Fax:
Practice Address - Street 1:2801 N DECATUR RD
Practice Address - Street 2:SUITE 295
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30033-5949
Practice Address - Country:US
Practice Address - Phone:404-778-6124
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-30
Last Update Date:2009-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA048900207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
H23401Medicare UPIN