Provider Demographics
NPI:1659349447
Name:BERGMAN, KENNETH R JR (MD)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:R
Last Name:BERGMAN
Suffix:JR
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 1:4116 BROWN MOUNTAIN LN
Mailing Address - Street 2:
Mailing Address - City:ELKTON
Mailing Address - State:VA
Mailing Address - Zip Code:22827-3409
Mailing Address - Country:US
Mailing Address - Phone:571-246-7223
Mailing Address - Fax:
Practice Address - Street 1:4116 BROWN MOUNTAIN LN
Practice Address - Street 2:
Practice Address - City:ELKTON
Practice Address - State:VA
Practice Address - Zip Code:22827-3409
Practice Address - Country:US
Practice Address - Phone:571-246-7223
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-09
Last Update Date:2025-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101102580207YS0012X, 207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YS0012XAllopathic & Osteopathic PhysiciansOtolaryngologySleep Medicine
No207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAP00406443OtherRR MEDICARE
VAP00406443OtherRR MEDICARE
I74290Medicare UPIN
DC021593L26Medicare PIN