Healthcare Provider Details

I. General information

NPI: 1083664064
Provider Name (Legal Business Name): JEFFREY ARIC BERGSMAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/11/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

75-5995 KUAKINI HWY
KAILUA KONA HI
96740-2144
US

IV. Provider business mailing address

76-715 AHU ST
KAILUA KONA HI
96740-2904
US

V. Phone/Fax

Practice location:
  • Phone: 808-329-0774
  • Fax: 808-329-0776
Mailing address:
  • Phone: 808-331-0617
  • Fax: 808-329-0776

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License NumberMD10538
License Number StateHI
# 2
Primary TaxonomyN
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License NumberME77724
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: