Provider Demographics
NPI:1326196841
Name:BERGSTROM, RICHARD WALTER (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:WALTER
Last Name:BERGSTROM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9135 SW BARNES RD STE 985
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97225-6699
Mailing Address - Country:US
Mailing Address - Phone:503-297-3336
Mailing Address - Fax:503-297-3338
Practice Address - Street 1:9135 SW BARNES RD STE 985
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225-6699
Practice Address - Country:US
Practice Address - Phone:503-297-3336
Practice Address - Fax:503-297-3338
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD16439207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR003736Medicaid
AB3016121OtherDEA
00WCGCXIMedicare ID - Type Unspecified
OR003736Medicaid