Provider Demographics
NPI:1982660700
Name:BERGSTROM, ROBERT W (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:W
Last Name:BERGSTROM
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 92900
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97292-0900
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:831 NW COUNCIL DR
Practice Address - Street 2:SUITE 125
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-3721
Practice Address - Country:US
Practice Address - Phone:503-661-3439
Practice Address - Fax:503-669-1360
Is Sole Proprietor?:No
Enumeration Date:2006-04-21
Last Update Date:2010-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD24029207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8372849Medicaid
OR286638Medicaid
OR113766Medicare ID - Type Unspecified
WA8372849Medicaid