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General NPI Number Information
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NPI Number | 1164647434
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Entity Type | Organization
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Legal Business Name | JOAN L BERGSTROM, MD PA
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Dates
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Enumeration Date | 04/13/2007
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Last Update Date | 02/22/2016
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Provider Practice Location Address
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Address Line | 1001 N WALDROP DR SUITE 505
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City | ARLINGTON
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State | TX
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Zip | 76012-4705
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Country | US
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Telephone | 817-277-9415
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Fax | 817-277-0360
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Provider Business Mailing Address
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Address Line | 1001 N WALDROP DR SUITE 505
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City | ARLINGTON
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State | TX
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Zip | 76012-4705
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Country | US
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Telephone | 817-277-9415
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Fax | 817-277-0360
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Authorized Official
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Title or Position | CEO
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Name | DR. JOAN L BERGSTROM
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Credential | M.D.
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Telephone | 817-277-9415
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM1300X
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Taxonomy Name | Multi-Specialty Clinic/Center
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License Number | L0505
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License Number State | TX
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Taxonomy #2
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Taxonomy Code | 261QM1300X
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Taxonomy Name | Multi-Specialty Clinic/Center
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License Number | G8579
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License Number State | TX
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