Provider Demographics
NPI:1659349447
Name:BERGMAN, KENNETH R JR (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:R
Last Name:BERGMAN
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:14631 LEE HWY
Mailing Address - Street 2:STE 413
Mailing Address - City:CENTREVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:20121-5824
Mailing Address - Country:US
Mailing Address - Phone:703-385-8222
Mailing Address - Fax:703-832-8809
Practice Address - Street 1:14631 LEE HWY
Practice Address - Street 2:STE 413
Practice Address - City:CENTREVILLE
Practice Address - State:VA
Practice Address - Zip Code:20121-5824
Practice Address - Country:US
Practice Address - Phone:703-385-8222
Practice Address - Fax:703-832-8809
Is Sole Proprietor?:No
Enumeration Date:2006-03-09
Last Update Date:2014-12-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VA0101102580207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAP00406443OtherRR MEDICARE
VAP00406443OtherRR MEDICARE
I74290Medicare UPIN
DC021593L26Medicare PIN