Provider Demographics
NPI:1669459061
Name:BERGENSTAL, RICHARD M (MD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:M
Last Name:BERGENSTAL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:3800 PARK NICOLLET BLVD
Mailing Address - Street 2:
Mailing Address - City:ST LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55416-2527
Mailing Address - Country:US
Mailing Address - Phone:952-993-1913
Mailing Address - Fax:952-993-1302
Practice Address - Street 1:3800 PARK NICOLLET BLVD
Practice Address - Street 2:
Practice Address - City:ST LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55416-2527
Practice Address - Country:US
Practice Address - Phone:952-993-3393
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-27
Last Update Date:2011-10-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN28104207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN416067300Medicaid
MN416067300Medicaid
MN460000060Medicare ID - Type Unspecified