Basic Information
| Provider Information | |||||||||
| NPI: | 1023110301 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BERGREN | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | D | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3400 DATA DR | ||||||||
| Address2: | |||||||||
| City: | RANCHO CORDOVA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956707956 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9163792915 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 13350 BIG BASIN WAY | ||||||||
| Address2: | |||||||||
| City: | BOULDER CREEK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 950069237 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8313386491 | ||||||||
| FaxNumber: | 9313382767 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/05/2006 | ||||||||
| LastUpdateDate: | 08/01/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 4035 | AK | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | G79510 | CA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | MD0772 | 05 | AK | MEDICAID |