Provider Demographics
NPI:1376690503
Name:BERGERON, JOHN (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:
Last Name:BERGERON
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 1:1961 W T C JESTER BLVD
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77008-1256
Mailing Address - Country:US
Mailing Address - Phone:713-868-3223
Mailing Address - Fax:713-861-8970
Practice Address - Street 1:1961 W T C JESTER BLVD
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77008-1256
Practice Address - Country:US
Practice Address - Phone:713-868-3223
Practice Address - Fax:713-861-8970
Is Sole Proprietor?:No
Enumeration Date:2007-01-03
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ3987174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXJ3987OtherSTATE MEDICAL LICENSE
TXF73151Medicare UPIN