Provider Demographics
NPI:1710092374
Name:BERGMAN, MYRON A (DPM)
Entity Type:Individual
Prefix:DR
First Name:MYRON
Middle Name:A
Last Name:BERGMAN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 WEBER AVE
Mailing Address - Street 2:
Mailing Address - City:HILLSBOROUGH
Mailing Address - State:NJ
Mailing Address - Zip Code:08844-7038
Mailing Address - Country:US
Mailing Address - Phone:908-904-9868
Mailing Address - Fax:908-904-9232
Practice Address - Street 1:766 RTE 202 206
Practice Address - Street 2:
Practice Address - City:BRIDGEWATER
Practice Address - State:NJ
Practice Address - Zip Code:08807
Practice Address - Country:US
Practice Address - Phone:908-429-5831
Practice Address - Fax:908-904-9232
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-21
Last Update Date:2009-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MD0000959213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0968706Medicaid
NJ0968706Medicaid
U24034Medicare UPIN
NJ0770720001Medicare NSC