Provider Demographics
NPI:1962663054
Name:BERGSTEN, MARK D (DO)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:D
Last Name:BERGSTEN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 936
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23501-0936
Mailing Address - Country:US
Mailing Address - Phone:757-446-5915
Mailing Address - Fax:757-446-5089
Practice Address - Street 1:721 FAIRFAX AVE
Practice Address - Street 2:3RD FLOOR
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23507-2007
Practice Address - Country:US
Practice Address - Phone:757-446-5915
Practice Address - Fax:757-446-5089
Is Sole Proprietor?:No
Enumeration Date:2008-06-20
Last Update Date:2015-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0102202299208100000X, 208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA10038954OtherSENTARA/OPTIMA PHYSICAL MEDICINE
VA360653OtherANTHEM
VAPAROtherUSA MANAGED CARE
VA10038956OtherSENTARA/OPTIMA DAY REHAB
NC10279OtherBC/BS
VA-017OtherTRICARE/CHAMPUS
VA9111220OtherAETNA
VAPAROtherCORVEL/CORCARE
VAPAROtherFIRST HEALTH COMMERCIAL/COVENTRY/SOUTHERN HEALTH
VA1962663054Medicaid
VA2190396OtherUHC/MAMSI
NC5910279Medicaid
VAPAROtherVA PREMIER HEALTH
VA8786189OtherCIGNA
VAPAROtherMULTIPLAN
VAPAROtherVA HEALTH NETWORK
VAP00680976Medicare PIN
VAPAROtherMULTIPLAN