Provider Demographics
NPI:1407016298
Name:BERGERON, THOMAS J JR
Entity Type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:J
Last Name:BERGERON
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39080 ROSARYVILLE RD
Mailing Address - Street 2:
Mailing Address - City:PONCHATOULA
Mailing Address - State:LA
Mailing Address - Zip Code:70454-7000
Mailing Address - Country:US
Mailing Address - Phone:985-974-3231
Mailing Address - Fax:225-294-5170
Practice Address - Street 1:39080 ROSARYVILLE RD
Practice Address - Street 2:
Practice Address - City:PONCHATOULA
Practice Address - State:LA
Practice Address - Zip Code:70454-7000
Practice Address - Country:US
Practice Address - Phone:985-974-3231
Practice Address - Fax:225-294-6217
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-15
Last Update Date:2008-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171WH0202XOther Service ProvidersContractorHome Modifications