Basic Information
| Provider Information | |||||||||
| NPI: | 1164474847 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BERGSTROM | ||||||||
| FirstName: | JON | ||||||||
| MiddleName: | F | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1888 | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 75403 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8009452455 | ||||||||
| FaxNumber: | 9034532541 | ||||||||
| Practice Location | |||||||||
| Address1: | 3535 S I-35 EAST | ||||||||
| Address2: | |||||||||
| City: | DENTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 76205 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9403876159 | ||||||||
| FaxNumber: | 9403823875 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2006 | ||||||||
| LastUpdateDate: | 05/19/2008 | ||||||||
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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 | 2085R0202X | E1502 | TX | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 136915904 | 05 | TX | MEDICAID |