Provider Demographics
NPI:1275610248
Name:BERGERON, MARK EDWARD I (DC)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:EDWARD
Last Name:BERGERON
Suffix:I
Gender:M
Credentials:DC
Other - Prefix:DR
Other - First Name:MARK
Other - Middle Name:EDWARD
Other - Last Name:BERGERON
Other - Suffix:I
Other - Last Name Type:Professional Name
Other - Credentials:DC
Mailing Address - Street 1:63 HOLTS POINT RD
Mailing Address - Street 2:
Mailing Address - City:SANDOWN
Mailing Address - State:NH
Mailing Address - Zip Code:03873-2522
Mailing Address - Country:US
Mailing Address - Phone:603-475-6767
Mailing Address - Fax:
Practice Address - Street 1:13 ORCHARD DR
Practice Address - Street 2:STE 6
Practice Address - City:LONDONDERRY
Practice Address - State:NH
Practice Address - Zip Code:03038-5124
Practice Address - Country:US
Practice Address - Phone:603-437-2181
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2016-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH7040903111N00000X
MA2844111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor