MEDICARE: DR. JOHN BERGERON MD

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	174400000X	Specialist	J3987	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	J3987	OTHER	TX	STATE MEDICAL LICENSE

General Provider Information

NPI Number	:	1376690503
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JOHN BERGERON MD

Provider Business Mailing Address
First Line	:	1961 W T C JESTER BLVD
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77008-1256
Country	:	US
Telephone Number	:	713-868-3223
Fax Number	:	713-861-8970

Provider Business Practice Location Address
First Line	:	1961 W T C JESTER BLVD
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77008-1256
Country	:	US
Telephone Number	:	713-868-3223
Fax Number	:	713-861-8970

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/03/2007
Last Update Date	:	07/09/2007

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