Provider Demographics
NPI:1669475562
Name:BERGMAN, STEPHEN (DO)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:
Last Name:BERGMAN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:741 NE 6TH ST
Mailing Address - Street 2:
Mailing Address - City:GRANTS PASS
Mailing Address - State:OR
Mailing Address - Zip Code:97526-1556
Mailing Address - Country:US
Mailing Address - Phone:541-471-2701
Mailing Address - Fax:541-471-1166
Practice Address - Street 1:741 NE 6TH ST
Practice Address - Street 2:
Practice Address - City:GRANTS PASS
Practice Address - State:OR
Practice Address - Zip Code:97526-1556
Practice Address - Country:US
Practice Address - Phone:541-471-2701
Practice Address - Fax:541-471-1166
Is Sole Proprietor?:No
Enumeration Date:2005-05-24
Last Update Date:2007-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDO21112207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR107215Medicare ID - Type Unspecified
OR130011Medicare ID - Type Unspecified
ORG77147Medicare UPIN