Healthcare Provider Details

I. General information

NPI: 1053756783
Provider Name (Legal Business Name): LEAH BERGMAN D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/08/2013
Last Update Date: 12/08/2020
Certification Date: 12/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9105 FRANKLIN SQUARE DR
BALTIMORE MD
21237-3930
US

IV. Provider business mailing address

175 E MAIN ST STE 200
HUNTINGTON NY
11743-2981
US

V. Phone/Fax

Practice location:
  • Phone: 410-574-1330
  • Fax:
Mailing address:
  • Phone: 631-549-5700
  • Fax: 631-424-6759

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberD87552
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: