Provider Demographics
NPI:1851640452
Name:BERGAMO, DAVID JUSTIN (PA-C)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:JUSTIN
Last Name:BERGAMO
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:38135 MARKET SQ
Mailing Address - Street 2:
Mailing Address - City:ZEPHYRHILLS
Mailing Address - State:FL
Mailing Address - Zip Code:33542-7505
Mailing Address - Country:US
Mailing Address - Phone:813-929-3600
Mailing Address - Fax:813-355-5901
Practice Address - Street 1:2352 BRUCE B DOWNS BLVD STE 101
Practice Address - Street 2:
Practice Address - City:WESLEY CHAPEL
Practice Address - State:FL
Practice Address - Zip Code:33544-9203
Practice Address - Country:US
Practice Address - Phone:813-929-3600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-29
Last Update Date:2022-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEJ3-00004312255A2300X
DE363AM0700X
FLPA9114583363A00000X
PART0052702255A2300X
DEC5-0001003363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical