Provider Demographics
NPI:1629003629
Name:BERGMAN, MARY ANN CONKLIN (MD)
Entity Type:Individual
Prefix:
First Name:MARY ANN
Middle Name:CONKLIN
Last Name:BERGMAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11511 SHADOW CREEK PKWY
Mailing Address - Street 2:
Mailing Address - City:PEARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:77584-7298
Mailing Address - Country:US
Mailing Address - Phone:713-442-0000
Mailing Address - Fax:
Practice Address - Street 1:6624 FANNIN ST
Practice Address - Street 2:19TH FLOOR, ST. LUKE'S TOWER
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-2312
Practice Address - Country:US
Practice Address - Phone:713-442-0000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2016-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF4758208000000X, 2080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX043688311Medicaid
TX043688313Medicaid
TX043688312Medicaid
TX043688313Medicaid
TX510539YKTVMedicare PIN
TX043688311Medicaid