Provider Demographics
NPI:1023110301
Name:BERGREN, JOHN D (MD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:D
Last Name:BERGREN
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 1:245 MOUNT HERMON RD STE L
Mailing Address - Street 2:
Mailing Address - City:SCOTTS VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:95066-4044
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:245 MOUNT HERMON RD STE L
Practice Address - Street 2:
Practice Address - City:SCOTTS VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95066-4044
Practice Address - Country:US
Practice Address - Phone:831-430-7203
Practice Address - Fax:831-430-7204
Is Sole Proprietor?:No
Enumeration Date:2006-09-05
Last Update Date:2023-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG79510207Q00000X
AK4035207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMD0772Medicaid
AKMD0772Medicaid
AKK150383Medicare PIN
AKK0000ZGBJVMedicare ID - Type UnspecifiedPRACTICE GROUP NUMBER