Provider Demographics
NPI:1578647376
Name:BERGMAN, MICHELLE ANN (OD)
Entity Type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:ANN
Last Name:BERGMAN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:MICHELLE
Other - Middle Name:MICHELLE
Other - Last Name:TILL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:15340 WEIR ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68137-5005
Mailing Address - Country:US
Mailing Address - Phone:402-932-9222
Mailing Address - Fax:
Practice Address - Street 1:15340 WEIR ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68137-5005
Practice Address - Country:US
Practice Address - Phone:402-932-9222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-25
Last Update Date:2015-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NENE 1022152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NENA1426OtherMEDICARE PTAN
NE10025787500Medicaid
NE10025787500Medicaid
NENA1426OtherMEDICARE PTAN