Healthcare Provider Details

I. General information

NPI: 1073040382
Provider Name (Legal Business Name): JOHN J BERGIN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2017
Last Update Date: 11/12/2024
Certification Date: 11/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

289 SW STONEGATE TER STE 103
LAKE CITY FL
32024-3457
US

IV. Provider business mailing address

104 WOODMONT BLVD STE 500
NASHVILLE TN
37205-2245
US

V. Phone/Fax

Practice location:
  • Phone: 386-755-1655
  • Fax: 386-628-9231
Mailing address:
  • Phone: 559-475-4151
  • Fax: 559-421-7004

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License NumberME168285
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: