Provider Demographics
NPI:1538101746
Name:BERGQUIST, BRADLEY J (MD)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:J
Last Name:BERGQUIST
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 1:527 SE BASELINE ST STE F
Mailing Address - Street 2:
Mailing Address - City:HILLSBORO
Mailing Address - State:OR
Mailing Address - Zip Code:97123-4149
Mailing Address - Country:US
Mailing Address - Phone:503-640-0493
Mailing Address - Fax:503-648-7643
Practice Address - Street 1:527 SE BASELINE ST STE F
Practice Address - Street 2:
Practice Address - City:HILLSBORO
Practice Address - State:OR
Practice Address - Zip Code:97123-4149
Practice Address - Country:US
Practice Address - Phone:503-640-0493
Practice Address - Fax:503-648-7643
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-12
Last Update Date:2010-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD13475174400000X, 207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORC92197Medicare UPIN