Provider Demographics
NPI:1982855664
Name:BERGSTROM, SUSANNE JANE (DOM)
Entity Type:Individual
Prefix:DR
First Name:SUSANNE
Middle Name:JANE
Last Name:BERGSTROM
Suffix:
Gender:F
Credentials:DOM
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Other - First Name:
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Mailing Address - Street 1:4020 PEGGY RD SE
Mailing Address - Street 2:SUITE D
Mailing Address - City:RIO RANCHO
Mailing Address - State:NM
Mailing Address - Zip Code:87124-1027
Mailing Address - Country:US
Mailing Address - Phone:505-896-2242
Mailing Address - Fax:505-896-8079
Practice Address - Street 1:4020 PEGGY RD SE
Practice Address - Street 2:SUITE D
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87124-1027
Practice Address - Country:US
Practice Address - Phone:505-896-2242
Practice Address - Fax:505-896-8079
Is Sole Proprietor?:No
Enumeration Date:2008-10-01
Last Update Date:2008-10-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NM496RX1171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist