Provider Demographics
NPI:1851398671
Name:BERGNER, GREGORY WALTER (MD)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:WALTER
Last Name:BERGNER
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:1111 EMERALD BAY RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH LAKE TAHOE
Mailing Address - State:CA
Mailing Address - Zip Code:96150-6207
Mailing Address - Country:US
Mailing Address - Phone:530-543-5659
Mailing Address - Fax:530-541-8723
Practice Address - Street 1:1067 4TH ST
Practice Address - Street 2:
Practice Address - City:SOUTH LAKE TAHOE
Practice Address - State:CA
Practice Address - Zip Code:96150-3459
Practice Address - Country:US
Practice Address - Phone:530-600-1960
Practice Address - Fax:530-542-4372
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG34890207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
A46135Medicare UPIN
NV1851398671Medicaid
NVV100702Medicare PIN
A46135Medicare UPIN