Provider Demographics
NPI:1437506813
Name:BERGMANN, JAMES RAY (MD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:RAY
Last Name:BERGMANN
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 1:2200 VICTORY AVE
Mailing Address - Street 2:UNIT 2404
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75219-7675
Mailing Address - Country:US
Mailing Address - Phone:802-598-3486
Mailing Address - Fax:
Practice Address - Street 1:2200 VICTORY AVE
Practice Address - Street 2:UNIT 2404
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75219-7675
Practice Address - Country:US
Practice Address - Phone:802-598-3486
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-16
Last Update Date:2016-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT042-0007035261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care