=====================================================
General NPI Number Information
=====================================================
NPI Number | 1518957067
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CLEMENS BERGWITZ MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/26/2005
-----------------------------------------------------
Last Update Date | 11/25/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 35 PARK ST YALE NEW HAVEN HOSPITAL, SMILOW CANCER CENTER
-----------------------------------------------------
City | NEW HAVEN
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06519-1110
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-200-3636
-----------------------------------------------------
Fax | 203-200-2159
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1 GILBERT ST ANLYAN CENTER, TAC S117
-----------------------------------------------------
City | NEW HAVEN
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06519-1621
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 617-726-8720
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RE0101X
-----------------------------------------------------
Taxonomy Name | Endocrinology, Diabetes & Metabolism Physician
-----------------------------------------------------
License Number | 52826
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------