Provider Demographics
NPI:1578644308
Name:GERALD J BERGMAN DPM PC
Entity Type:Organization
Organization Name:GERALD J BERGMAN DPM PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PODIATRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:GERLAD
Authorized Official - Middle Name:J
Authorized Official - Last Name:BERGMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:516-781-1943
Mailing Address - Street 1:1400 WANTAGH AVE
Mailing Address - Street 2:SUITE 202
Mailing Address - City:WANTAGH
Mailing Address - State:NY
Mailing Address - Zip Code:11793-2210
Mailing Address - Country:US
Mailing Address - Phone:516-781-1943
Mailing Address - Fax:516-781-1943
Practice Address - Street 1:1400 WANTAGH AVE
Practice Address - Street 2:SUITE 202
Practice Address - City:WANTAGH
Practice Address - State:NY
Practice Address - Zip Code:11793-2210
Practice Address - Country:US
Practice Address - Phone:516-781-1943
Practice Address - Fax:516-781-1943
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN0018861213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00401538Medicaid
0030766OtherGHI
P2890117OtherOXFORD
0030766OtherGHI
P2890117OtherOXFORD