Healthcare Provider Details

I. General information

NPI: 1669393229
Provider Name (Legal Business Name): SAMUEL JAMES BERGMAN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/21/2026
Last Update Date: 07/21/2026
Certification Date: 07/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18001 BURBANK BLVD
ENCINO CA
91316-1605
US

IV. Provider business mailing address

18001 BURBANK BLVD
ENCINO CA
91316-1605
US

V. Phone/Fax

Practice location:
  • Phone: 818-675-0255
  • Fax: 818-675-0255
Mailing address:
  • Phone: 818-675-0255
  • Fax: 818-675-0255

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License NumberRT1440450426
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: