Provider Demographics
NPI:1528377199
Name:BERGERON, STEPHANE (MD)
Entity Type:Individual
Prefix:
First Name:STEPHANE
Middle Name:
Last Name:BERGERON
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 1:1020 GULF BREEZE PKWY
Mailing Address - Street 2:
Mailing Address - City:GULF BREEZE
Mailing Address - State:FL
Mailing Address - Zip Code:32561-4838
Mailing Address - Country:US
Mailing Address - Phone:850-916-8583
Mailing Address - Fax:850-916-8579
Practice Address - Street 1:1040 GULF BREEZE PKWY
Practice Address - Street 2:SUITE 200
Practice Address - City:GULF BREEZE
Practice Address - State:FL
Practice Address - Zip Code:32561-7809
Practice Address - Country:US
Practice Address - Phone:850-916-3700
Practice Address - Fax:850-916-3710
Is Sole Proprietor?:No
Enumeration Date:2010-09-30
Last Update Date:2010-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME108283207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery