Provider Demographics
NPI:1891988242
Name:BERGVALL, ETHAN SCHUYLER (MD)
Entity Type:Individual
Prefix:DR
First Name:ETHAN
Middle Name:SCHUYLER
Last Name:BERGVALL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 9007
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22906-9007
Mailing Address - Country:US
Mailing Address - Phone:434-295-1000
Mailing Address - Fax:434-972-4266
Practice Address - Street 1:1240 LEE ST
Practice Address - Street 2:
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22908-0817
Practice Address - Country:US
Practice Address - Phone:434-924-9333
Practice Address - Fax:434-243-3938
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-20
Last Update Date:2023-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101268271207U00000X
HIMD14377207UN0902X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207UN0902XAllopathic & Osteopathic PhysiciansNuclear MedicineNuclear Imaging & Therapy
Yes207U00000XAllopathic & Osteopathic PhysiciansNuclear Medicine