Healthcare Provider Details

I. General information

NPI: 1669475562
Provider Name (Legal Business Name): STEPHEN BERGMAN D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2005
Last Update Date: 07/11/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

741 NE 6TH ST
GRANTS PASS OR
97526-1556
US

IV. Provider business mailing address

741 NE 6TH ST
GRANTS PASS OR
97526-1556
US

V. Phone/Fax

Practice location:
  • Phone: 541-471-2701
  • Fax: 541-471-1166
Mailing address:
  • Phone: 541-471-2701
  • Fax: 541-471-1166

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberDO21112
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: