Provider Demographics
NPI:1013939578
Name:PETERSEN, DIANE ELAINE BERGMAN (MD)
Entity Type:Individual
Prefix:MRS
First Name:DIANE
Middle Name:ELAINE BERGMAN
Last Name:PETERSEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:940 CENTRAL PARK DRIVE
Mailing Address - Street 2:#209
Mailing Address - City:STEAMBOAT SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80487
Mailing Address - Country:US
Mailing Address - Phone:970-879-3738
Mailing Address - Fax:970-870-6441
Practice Address - Street 1:940 CENTRAL PARK DRIVE
Practice Address - Street 2:#209
Practice Address - City:STEAMBOAT SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80487
Practice Address - Country:US
Practice Address - Phone:970-879-3738
Practice Address - Fax:970-870-6441
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2011-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN30507174400000X
CO46731207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO46731OtherCOLORADO STATE LICENSE
D98282Medicare UPIN
MND98282Medicare UPIN