Provider Demographics
NPI:1760454391
Name:BERGEN, EDWARD CARL (DO)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:CARL
Last Name:BERGEN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 122152
Mailing Address - Street 2:DEPT 2152
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75312-2152
Mailing Address - Country:US
Mailing Address - Phone:337-494-2772
Mailing Address - Fax:337-494-2928
Practice Address - Street 1:1717 OAK PARK BLVD FL 2
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70601-8990
Practice Address - Country:US
Practice Address - Phone:337-494-3278
Practice Address - Fax:337-494-3240
Is Sole Proprietor?:No
Enumeration Date:2006-02-07
Last Update Date:2022-03-25
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
LADO000438207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology