Provider Demographics
NPI:1508285909
Name:BERGENE, JAMES DAVID (MD)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:DAVID
Last Name:BERGENE
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 550
Mailing Address - Street 2:
Mailing Address - City:TORRINGTON
Mailing Address - State:WY
Mailing Address - Zip Code:82240-0550
Mailing Address - Country:US
Mailing Address - Phone:307-630-1665
Mailing Address - Fax:
Practice Address - Street 1:489 STATE ST
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-6616
Practice Address - Country:US
Practice Address - Phone:207-973-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-14
Last Update Date:2023-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.0067337207L00000X
WY11718A207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO9000199882Medicaid