Provider Demographics
NPI:1720183148
Name:BERGERON, WILLIAM NOAH (MD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:NOAH
Last Name:BERGERON
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:PO BOX 41574
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70835-1574
Mailing Address - Country:US
Mailing Address - Phone:225-922-7885
Mailing Address - Fax:225-922-9114
Practice Address - Street 1:8768 QUARTERS LAKE RD
Practice Address - Street 2:SUITE 4
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70809
Practice Address - Country:US
Practice Address - Phone:225-922-7885
Practice Address - Fax:225-922-9114
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA011625207ZP0102X, 2084P0800X, 2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Not Answered2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Not Answered2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1383198Medicaid
LA54832Medicare ID - Type Unspecified
C67663Medicare UPIN