Provider Demographics
NPI:1457401101
Name:BERGMAN, RANDY N (MD)
Entity Type:Individual
Prefix:DR
First Name:RANDY
Middle Name:N
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 1:8109 FREDERICKSBURG RD
Mailing Address - Street 2:PHYSICIAN PRACTICE SERVICES
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78229-3311
Mailing Address - Country:US
Mailing Address - Phone:210-650-9669
Mailing Address - Fax:210-650-0750
Practice Address - Street 1:12702 IH35 N
Practice Address - Street 2:
Practice Address - City:LIVE OAK
Practice Address - State:TX
Practice Address - Zip Code:78233-2609
Practice Address - Country:US
Practice Address - Phone:210-650-9669
Practice Address - Fax:210-650-0750
Is Sole Proprietor?:No
Enumeration Date:2007-01-12
Last Update Date:2014-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG2903207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX134941711Medicaid
P01136131OtherRAILROAD MEDICARE
TXC13397Medicare UPIN
P01136131OtherRAILROAD MEDICARE
TX8F8210Medicare PIN
TXTXB124707Medicare PIN
TX8CU221OtherBCBS
TX1349417-09Medicaid