Provider Demographics
NPI:1497721195
Name:BERGESON, LARS (MD)
Entity Type:Individual
Prefix:DR
First Name:LARS
Middle Name:
Last Name:BERGESON
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:PO BOX 609
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:UT
Mailing Address - Zip Code:84332-0609
Mailing Address - Country:US
Mailing Address - Phone:435-752-0330
Mailing Address - Fax:435-755-0922
Practice Address - Street 1:382 W 280 N
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:UT
Practice Address - Zip Code:84332-9707
Practice Address - Country:US
Practice Address - Phone:435-752-0330
Practice Address - Fax:435-755-0922
Is Sole Proprietor?:No
Enumeration Date:2006-02-23
Last Update Date:2009-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT170371-1205207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000011835Medicare ID - Type Unspecified
UTC-63887Medicare UPIN