Provider Demographics
NPI:1013912252
Name:BERGMAN, KENNETH ROBERT (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:ROBERT
Last Name:BERGMAN
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 1:13890 BRADDOCK RD
Mailing Address - Street 2:STE 206
Mailing Address - City:CENTREVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:20121-2437
Mailing Address - Country:US
Mailing Address - Phone:703-263-2333
Mailing Address - Fax:703-263-0361
Practice Address - Street 1:13890 BRADDOCK RD
Practice Address - Street 2:STE 206
Practice Address - City:CENTREVILLE
Practice Address - State:VA
Practice Address - Zip Code:20121-2437
Practice Address - Country:US
Practice Address - Phone:703-263-2333
Practice Address - Fax:703-263-0361
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-15
Last Update Date:2007-07-08
Deactivation Date:2006-03-17
Deactivation Code:
Reactivation Date:2006-03-31
Provider Licenses
StateLicense IDTaxonomies
VA0101025702207KA0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207KA0200XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyAllergy