Provider Demographics
NPI:1639122013
Name:BERGSTROM, JOHN O (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:O
Last Name:BERGSTROM
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 1:9155 SW BARNES RD,
Mailing Address - Street 2:SUITE 634
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97225-6633
Mailing Address - Country:US
Mailing Address - Phone:503-297-4123
Mailing Address - Fax:503-297-0344
Practice Address - Street 1:9155 SW BARNES RD,
Practice Address - Street 2:SUITE 634
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225-6633
Practice Address - Country:US
Practice Address - Phone:503-297-4123
Practice Address - Fax:503-297-0344
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD06700207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORMD06700OtherLICENSE
ORROOOOBKWBPMedicare ID - Type Unspecified
ORMD06700OtherLICENSE