Healthcare Provider Details

I. General information

NPI: 1679557367
Provider Name (Legal Business Name): RICHARD T BERGSTROM M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/06/2005
Last Update Date: 09/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3305 PLACER ST STE A
REDDING CA
96001-2364
US

IV. Provider business mailing address

3305 PLACER ST STE A
REDDING CA
96001-2364
US

V. Phone/Fax

Practice location:
  • Phone: 530-243-3687
  • Fax: 530-243-3383
Mailing address:
  • Phone: 530-243-3687
  • Fax: 530-243-3383

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License NumberA80467
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: