Provider Demographics
NPI:1407990120
Name:BERGERON, PHYLLIS ANN (MD)
Entity Type:Individual
Prefix:DR
First Name:PHYLLIS
Middle Name:ANN
Last Name:BERGERON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3069 FOX SEDGE PL
Mailing Address - Street 2:
Mailing Address - City:HIGHLANDS RANCH
Mailing Address - State:CO
Mailing Address - Zip Code:80126-7595
Mailing Address - Country:US
Mailing Address - Phone:303-263-7035
Mailing Address - Fax:
Practice Address - Street 1:1375 E 19TH AVE
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80218-1114
Practice Address - Country:US
Practice Address - Phone:303-812-3600
Practice Address - Fax:303-812-4223
Is Sole Proprietor?:No
Enumeration Date:2007-02-16
Last Update Date:2020-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO30486207YX0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YX0007XAllopathic & Osteopathic PhysiciansOtolaryngologyPlastic Surgery within the Head & Neck
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01304864Medicaid
CO006041OtherKAISER-COMMERCIAL NUMBER
COD83659Medicare UPIN
CO006041OtherKAISER-COMMERCIAL NUMBER
COCO304328Medicare PIN