Provider Demographics
NPI:1750310231
Name:BERGMAN, MICHELE DIAHANN (MD)
Entity Type:Individual
Prefix:
First Name:MICHELE
Middle Name:DIAHANN
Last Name:BERGMAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MICHELE
Other - Middle Name:DIAHANN
Other - Last Name:BRATHWAITE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD,
Mailing Address - Street 1:350 JOHN MUIR PKWY STE 140
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:94513-5190
Mailing Address - Country:US
Mailing Address - Phone:925-513-2483
Mailing Address - Fax:925-513-8226
Practice Address - Street 1:1120 2ND ST
Practice Address - Street 2:
Practice Address - City:BRENTWOOD
Practice Address - State:CA
Practice Address - Zip Code:94513-2234
Practice Address - Country:US
Practice Address - Phone:925-513-2483
Practice Address - Fax:925-513-4957
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2017-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA77659207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAI20251Medicare UPIN