Provider Demographics
NPI:1649216524
Name:BERGQVIST, GUNNAR EO (MD)
Entity type:Individual
Prefix:DR
First Name:GUNNAR
Middle Name:EO
Last Name:BERGQVIST
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:410 CRANBERRY ST
Mailing Address - Street 2:SUITE 310
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16507-1067
Mailing Address - Country:US
Mailing Address - Phone:814-480-8220
Mailing Address - Fax:814-480-8225
Practice Address - Street 1:410 CRANBERRY ST
Practice Address - Street 2:SUITE 310
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16507-1067
Practice Address - Country:US
Practice Address - Phone:814-480-8220
Practice Address - Fax:814-480-8225
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2020-05-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PAMD4185812082S0099X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2082S0099XAllopathic & Osteopathic PhysiciansPlastic SurgeryPlastic Surgery Within the Head and Neck
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAH65084Medicare UPIN
PA074512Medicare ID - Type Unspecified