Provider Demographics
NPI:1982934303
Name:BERGMAN, GORDON JOHN
Entity Type:Individual
Prefix:MR
First Name:GORDON
Middle Name:JOHN
Last Name:BERGMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2821 MONTWOOD LN
Mailing Address - Street 2:
Mailing Address - City:BREMERTON
Mailing Address - State:WA
Mailing Address - Zip Code:98312-1936
Mailing Address - Country:US
Mailing Address - Phone:360-689-3101
Mailing Address - Fax:
Practice Address - Street 1:2821 MONTWOOD LN
Practice Address - Street 2:
Practice Address - City:BREMERTON
Practice Address - State:WA
Practice Address - Zip Code:98312-1936
Practice Address - Country:US
Practice Address - Phone:360-689-3101
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-07
Last Update Date:2012-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman