Healthcare Provider Details

I. General information

NPI: 1477143949
Provider Name (Legal Business Name): DUSTIN MICHAEL BERGMAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/19/2021
Last Update Date: 10/15/2021
Certification Date: 10/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 CHILDRENS PLZ
DAYTON OH
45404-1815
US

IV. Provider business mailing address

1430 ABBEY PARK PL
XENIA OH
45385-7512
US

V. Phone/Fax

Practice location:
  • Phone: 937-641-3477
  • Fax: 937-641-5410
Mailing address:
  • Phone: 419-733-6536
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LP3000X
TaxonomyPediatric Anesthesiology Physician
License NumberAPRN.CRNA.0020210
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: