Provider Demographics
NPI:1457680332
Name:BERGERON, WILTON LEE (M D)
Entity Type:Individual
Prefix:DR
First Name:WILTON
Middle Name:LEE
Last Name:BERGERON
Suffix:
Gender:M
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1505 WESTGATE RD
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70506-2742
Mailing Address - Country:US
Mailing Address - Phone:337-981-2588
Mailing Address - Fax:
Practice Address - Street 1:1505 WESTGATE RD
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70506-2742
Practice Address - Country:US
Practice Address - Phone:337-981-2588
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-23
Last Update Date:2009-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA8170207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology