Healthcare Provider Details

I. General information

NPI: 1164653929
Provider Name (Legal Business Name): JEFFERY JOSEPH BERGMAN D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2009
Last Update Date: 01/08/2026
Certification Date: 01/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1350 HICKORY ST
MELBOURNE FL
32901-3224
US

IV. Provider business mailing address

4690 RUMMELL RD BERGMAN MEDICAL LLC
SAINT CLOUD FL
34771-9696
US

V. Phone/Fax

Practice location:
  • Phone: 321-434-7208
  • Fax: 321-434-5344
Mailing address:
  • Phone: 407-680-4182
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4739
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberOS11615
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number103328
License Number StateWI
# 4
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberP0550
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: