Healthcare Provider Details

I. General information

NPI: 1982933750
Provider Name (Legal Business Name): LARS BERGESON, M.D., PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/08/2009
Last Update Date: 12/08/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

382 W 280 N
PROVIDENCE UT
84332-0609
US

IV. Provider business mailing address

PO BOX 609 382 W 280 N
PROVIDENCE UT
84332-0609
US

V. Phone/Fax

Practice location:
  • Phone: 435-752-0330
  • Fax: 435-755-0922
Mailing address:
  • Phone: 435-752-0330
  • Fax: 435-755-0922

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code305S00000X
TaxonomyPoint of Service
License Number
License Number State

VIII. Authorized Official

Name: DR. LARS BERGESON
Title or Position: OWNER
Credential: M.D.
Phone: 435-752-0330