Provider Demographics
NPI:1861466583
Name:BERGEN, RANDALL P (DPM)
Entity Type:Individual
Prefix:
First Name:RANDALL
Middle Name:P
Last Name:BERGEN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:505 5TH ST STE 714
Mailing Address - Street 2:
Mailing Address - City:SIOUX CITY
Mailing Address - State:IA
Mailing Address - Zip Code:51101-1509
Mailing Address - Country:US
Mailing Address - Phone:712-255-3526
Mailing Address - Fax:712-255-0298
Practice Address - Street 1:505 5TH ST
Practice Address - Street 2:SUITE 714
Practice Address - City:SIOUX CITY
Practice Address - State:IA
Practice Address - Zip Code:51101-1500
Practice Address - Country:US
Practice Address - Phone:712-255-3526
Practice Address - Fax:712-255-0298
Is Sole Proprietor?:No
Enumeration Date:2006-02-17
Last Update Date:2008-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA00319213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist