Provider Demographics
NPI:1720007826
Name:BERGEN, WAYNE Y (MD)
Entity Type:Individual
Prefix:
First Name:WAYNE
Middle Name:Y
Last Name:BERGEN
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 1:134 BUSINESS PARK DR
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23462-6523
Mailing Address - Country:US
Mailing Address - Phone:757-473-0055
Mailing Address - Fax:
Practice Address - Street 1:600 GRESHAM DR
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23507-1904
Practice Address - Country:US
Practice Address - Phone:757-668-3871
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2007-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA6086748Medicaid
VA5708931Medicaid
50001213Medicare ID - Type Unspecified
50000794Medicare ID - Type Unspecified
VA5708931Medicaid