Provider Demographics
NPI:1609966613
Name:BERGERE, LARRY (MD)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:
Last Name:BERGERE
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 1:105 CARNEGIE PL
Mailing Address - Street 2:ST 103
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30214-3980
Mailing Address - Country:US
Mailing Address - Phone:770-716-7999
Mailing Address - Fax:770-716-8444
Practice Address - Street 1:105 CARNEGIE PL
Practice Address - Street 2:ST 103
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214-3980
Practice Address - Country:US
Practice Address - Phone:770-716-7999
Practice Address - Fax:770-716-8444
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA44166207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA11BDPKNMedicare ID - Type Unspecified
GAG81495Medicare UPIN