Provider Demographics
NPI:1912985128
Name:BERGEN, DEBORAH R (MD)
Entity Type:Individual
Prefix:
First Name:DEBORAH
Middle Name:R
Last Name:BERGEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:DEBORAH
Other - Middle Name:
Other - Last Name:SCHMIDT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6 HOSPITAL PLZ
Mailing Address - Street 2:
Mailing Address - City:CLARKSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:26301-9316
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:40 COMMERCE DR
Practice Address - Street 2:STE B
Practice Address - City:WESTOVER
Practice Address - State:WV
Practice Address - Zip Code:26501-3952
Practice Address - Country:US
Practice Address - Phone:304-241-1708
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-06
Last Update Date:2017-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04261582084P0800X
WV272922084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100185750AMedicaid
40943Medicare ID - Type Unspecified
KS100185750AMedicaid