Provider Demographics
NPI:1629249842
Name:ROGER L. BERGERON, O.D.P.A.
Entity Type:Organization
Organization Name:ROGER L. BERGERON, O.D.P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:L
Authorized Official - Last Name:BERGERON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:207-784-0153
Mailing Address - Street 1:585 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ME
Mailing Address - Zip Code:04240-5945
Mailing Address - Country:US
Mailing Address - Phone:207-784-0153
Mailing Address - Fax:207-786-6725
Practice Address - Street 1:585 MAIN ST
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ME
Practice Address - Zip Code:04240-5945
Practice Address - Country:US
Practice Address - Phone:207-784-0153
Practice Address - Fax:207-786-6725
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-15
Last Update Date:2008-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME410002654OtherRAIROAD MEDICARE
ME114880099Medicaid
ME0369960001Medicare NSC
ME703909Medicare PIN
ME410002654OtherRAIROAD MEDICARE