Provider Demographics
NPI:1467514356
Name:BERGERON, ROGER L (OD)
Entity Type:Individual
Prefix:DR
First Name:ROGER
Middle Name:L
Last Name:BERGERON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:585 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ME
Mailing Address - Zip Code:04240-5945
Mailing Address - Country:US
Mailing Address - Phone:207-784-0153
Mailing Address - Fax:207-786-6725
Practice Address - Street 1:585 MAIN ST
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ME
Practice Address - Zip Code:04240-5945
Practice Address - Country:US
Practice Address - Phone:207-784-0153
Practice Address - Fax:207-786-6725
Is Sole Proprietor?:No
Enumeration Date:2006-12-15
Last Update Date:2008-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEOPT598152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME114880099Medicaid
ME410002654OtherRAILROAD MEDICARE-UHC
ME114880099Medicaid
ME703909Medicare PIN
ME410002654OtherRAILROAD MEDICARE-UHC