Provider Demographics
NPI:1568442846
Name:BERGERON, MARC GEORGE (OD)
Entity Type:Individual
Prefix:DR
First Name:MARC
Middle Name:GEORGE
Last Name:BERGERON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:408 N MAYS ST
Mailing Address - Street 2:
Mailing Address - City:ROUND ROCK
Mailing Address - State:TX
Mailing Address - Zip Code:78664-4317
Mailing Address - Country:US
Mailing Address - Phone:512-244-2003
Mailing Address - Fax:512-218-4743
Practice Address - Street 1:408 N MAYS ST
Practice Address - Street 2:
Practice Address - City:ROUND ROCK
Practice Address - State:TX
Practice Address - Zip Code:78664-4317
Practice Address - Country:US
Practice Address - Phone:512-244-2003
Practice Address - Fax:512-218-4743
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2584T152W00000X, 152WV0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered152W00000XEye and Vision Services ProvidersOptometrist
Not Answered152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX80773QOtherBLUE CROSS BLUE SHIELD