Provider Demographics
NPI:1528039641
Name:BERGAMO, DALE (MD)
Entity Type:Individual
Prefix:
First Name:DALE
Middle Name:
Last Name:BERGAMO
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 917770
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32891-7770
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12901 BRUCE B DOWNS BLVD
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33612-4742
Practice Address - Country:US
Practice Address - Phone:813-259-8803
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-27
Last Update Date:2011-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME971432080P0208X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0208XAllopathic & Osteopathic PhysiciansPediatricsPediatric Infectious Diseases
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL68337OtherBLUE CROSS BLUE SHIELD
FL276902600Medicaid
FLF01793Medicare UPIN