Provider Demographics
NPI:1467575654
Name:BERGESON, JEFFREY M (DO)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:M
Last Name:BERGESON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10470 OLD PLACERVILLE RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95827-2539
Mailing Address - Country:US
Mailing Address - Phone:800-470-0071
Mailing Address - Fax:
Practice Address - Street 1:11795 EDUCATION ST
Practice Address - Street 2:SUITE 110
Practice Address - City:AUBURN
Practice Address - State:CA
Practice Address - Zip Code:95602-2454
Practice Address - Country:US
Practice Address - Phone:530-886-6820
Practice Address - Fax:530-886-6821
Is Sole Proprietor?:No
Enumeration Date:2007-04-10
Last Update Date:2015-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A9815207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00AX98150Medicaid
CA00AX98150Medicaid
CA020A98152Medicare PIN