MEDICARE: DWIGHT A BERGQUIST MD INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084P0800X	Psychiatry Physician	G38711	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1053407544	OTHER	CA	TYPE 1 NPI

General Provider Information

NPI Number	:	1003110495
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DWIGHT A BERGQUIST MD INC

Provider Business Mailing Address
First Line	:	5230 N. CLARK AVENUE
Second Line	:	SUITE 10
City	:	LAKEWOOD
State	:	CA
Zip	:	90712-2649
Country	:	US
Telephone Number	:	562-804-4428
Fax Number	:	562-867-5264

Provider Business Practice Location Address
First Line	:	5230 N. CLARK AVENUE
Second Line	:	SUITE 10
City	:	LAKEWOOD
State	:	CA
Zip	:	90712-2649
Country	:	US
Telephone Number	:	562-804-4428
Fax Number	:	562-867-5264

Authorized Official
Title or Position	:	CEO
Name	:	DR. DWIGHT A BERGQUIST
Credential	:	M.D.
Telephone Number	:	562-804-4428

Provider Enumeration Date	:	12/29/2010
Last Update Date	:	06/04/2013

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