Provider Demographics
NPI:1770626061
Name:BERGTHOLD, MARK JEROME (DC)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:JEROME
Last Name:BERGTHOLD
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2707 KIMBERLY RD
Mailing Address - Street 2:
Mailing Address - City:BETTENDORF
Mailing Address - State:IA
Mailing Address - Zip Code:52722
Mailing Address - Country:US
Mailing Address - Phone:563-359-0073
Mailing Address - Fax:563-359-0073
Practice Address - Street 1:2707 KIMBERLY RD
Practice Address - Street 2:
Practice Address - City:BETTENDORF
Practice Address - State:IA
Practice Address - Zip Code:52722
Practice Address - Country:US
Practice Address - Phone:563-359-0073
Practice Address - Fax:563-359-0073
Is Sole Proprietor?:No
Enumeration Date:2007-02-15
Last Update Date:2008-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAA05483111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1007146Medicaid
IA1007146Medicaid
IL556Medicare PIN