Healthcare Provider Details

I. General information

NPI: 1245878172
Provider Name (Legal Business Name): GARIN B BERGESON DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/10/2019
Last Update Date: 05/09/2025
Certification Date: 05/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13995 W STATLER BLVD STE 200
SURPRISE AZ
85374-5503
US

IV. Provider business mailing address

13995 W STATLER BLVD STE 200
SURPRISE AZ
85374-5503
US

V. Phone/Fax

Practice location:
  • Phone: 623-876-3870
  • Fax: 623-285-2707
Mailing address:
  • Phone: 623-478-3100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number011339
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: