Healthcare Provider Details

I. General information

NPI: 1417936394
Provider Name (Legal Business Name): CARL T BERGREN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/10/2006
Last Update Date: 08/01/2025
Certification Date: 08/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6161 S YALE AVE
TULSA OK
74136-1902
US

IV. Provider business mailing address

6600 S YALE AVE SUITE 1400
TULSA OK
74136-3347
US

V. Phone/Fax

Practice location:
  • Phone: 918-494-1805
  • Fax:
Mailing address:
  • Phone: 918-488-6001
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2086S0102X
TaxonomySurgical Critical Care Physician
License Number26994
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number90704
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: