Healthcare Provider Details

I. General information

NPI: 1568412005
Provider Name (Legal Business Name): GARY J BERGMAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/12/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6303 LITTLE RIVER TPKE #300
ALEXANDRIA VA
22312
US

IV. Provider business mailing address

3802 LATROBE COURT
FAIRFAX VA
22031
US

V. Phone/Fax

Practice location:
  • Phone: 703-914-8989
  • Fax: 703-914-5494
Mailing address:
  • Phone: 703-591-5775
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number0101030752
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: