Provider Demographics
NPI:1407937139
Name:BERGSTROM, CARL RAMOND (MD)
Entity Type:Individual
Prefix:DR
First Name:CARL
Middle Name:RAMOND
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:PO BOX 221698
Mailing Address - Street 2:
Mailing Address - City:CARMEL
Mailing Address - State:CA
Mailing Address - Zip Code:93922-1698
Mailing Address - Country:US
Mailing Address - Phone:831-624-3077
Mailing Address - Fax:831-624-8662
Practice Address - Street 1:26366 CARMEL RANCHO LANE
Practice Address - Street 2:STE H
Practice Address - City:CARMEL
Practice Address - State:CA
Practice Address - Zip Code:93923
Practice Address - Country:US
Practice Address - Phone:831-624-3077
Practice Address - Fax:831-624-8662
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG598660207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G598660Medicare ID - Type Unspecified
E44348Medicare UPIN