Provider Demographics
NPI:1245878172
Name:BERGESON, GARIN B (DO)
Entity type:Individual
Prefix:
First Name:GARIN
Middle Name:B
Last Name:BERGESON
Suffix:
Gender:
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13995 W STATLER BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:SURPRISE
Mailing Address - State:AZ
Mailing Address - Zip Code:85374-5503
Mailing Address - Country:US
Mailing Address - Phone:623-478-3100
Mailing Address - Fax:
Practice Address - Street 1:13995 W STATLER BLVD STE 200
Practice Address - Street 2:
Practice Address - City:SURPRISE
Practice Address - State:AZ
Practice Address - Zip Code:85374-5503
Practice Address - Country:US
Practice Address - Phone:623-876-3870
Practice Address - Fax:623-285-2707
Is Sole Proprietor?:No
Enumeration Date:2019-12-10
Last Update Date:2025-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ011339207QS0010X, 207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ011339OtherARIZONA BOARD OF OSTEOPATHIC EXAMINERS
NONEOtherNONE