Provider Demographics
NPI:1497755318
Name:BERGAMASCHI, ROBERTO CM (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERTO
Middle Name:CM
Last Name:BERGAMASCHI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:HSC T19 020
Mailing Address - Street 2:
Mailing Address - City:STONY BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11794-8191
Mailing Address - Country:US
Mailing Address - Phone:631-444-2704
Mailing Address - Fax:631-444-6348
Practice Address - Street 1:HSC T19-020
Practice Address - Street 2:
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11794-8191
Practice Address - Country:US
Practice Address - Phone:631-444-2704
Practice Address - Fax:631-444-6348
Is Sole Proprietor?:No
Enumeration Date:2005-07-22
Last Update Date:2017-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD420914208600000X
NY250434-1208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAH86132Medicare UPIN