Provider Demographics
NPI:1568511095
Name:BERGSTROM, JODI ANN (OD)
Entity Type:Individual
Prefix:
First Name:JODI
Middle Name:ANN
Last Name:BERGSTROM
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:416 SUPERIOR AVENUE
Mailing Address - Street 2:PO BOX 400
Mailing Address - City:CENTURIA
Mailing Address - State:WI
Mailing Address - Zip Code:54824
Mailing Address - Country:US
Mailing Address - Phone:715-646-1336
Mailing Address - Fax:
Practice Address - Street 1:416 SUPERIOR AVENUE
Practice Address - Street 2:
Practice Address - City:CENTURIA
Practice Address - State:WI
Practice Address - Zip Code:54824
Practice Address - Country:US
Practice Address - Phone:715-646-1336
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2281152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38594500Medicaid
WIT85024Medicare UPIN