Provider Demographics
NPI:1982021895
Name:BERGMAN, CARL JOHAN CHRISTIAN (MD)
Entity Type:Individual
Prefix:
First Name:CARL
Middle Name:JOHAN CHRISTIAN
Last Name:BERGMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:CHRISTIAN
Other - Middle Name:CARL
Other - Last Name:BERGMAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 91734
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23291-1734
Mailing Address - Country:US
Mailing Address - Phone:804-358-6100
Mailing Address - Fax:804-342-7619
Practice Address - Street 1:2116 W LABURNUM AVE
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23227
Practice Address - Country:US
Practice Address - Phone:804-254-3500
Practice Address - Fax:804-254-1616
Is Sole Proprietor?:No
Enumeration Date:2014-03-28
Last Update Date:2018-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101260033207RG0300X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA15296065000398OtherMEDICARE PECOS, DCN