Healthcare Provider Details

I. General information

NPI: 1255411419
Provider Name (Legal Business Name): BRYAN LEONARD BERGHOUT DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/16/2006
Last Update Date: 07/07/2026
Certification Date: 07/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10561 JEFFREYS ST STE 110
HENDERSON NV
89052-4267
US

IV. Provider business mailing address

PO BOX 845038
LOS ANGELES CA
90084-5038
US

V. Phone/Fax

Practice location:
  • Phone: 702-456-3668
  • Fax:
Mailing address:
  • Phone: 415-645-4525
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number2124
License Number StateNV
# 2
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberPO00000813
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: