Basic Information
| Provider Information | |||||||||
| NPI: | 1285049940 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BERGMAN | ||||||||
| FirstName: | CORY | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2800 3RD ST | ||||||||
| Address2: | |||||||||
| City: | RAPID CITY | ||||||||
| State: | SD | ||||||||
| PostalCode: | 577017374 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6057193110 | ||||||||
| FaxNumber: | 6053410278 | ||||||||
| Practice Location | |||||||||
| Address1: | 2800 3RD ST | ||||||||
| Address2: | |||||||||
| City: | RAPID CITY | ||||||||
| State: | SD | ||||||||
| PostalCode: | 577017374 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6057193110 | ||||||||
| FaxNumber: | 6053410278 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/21/2014 | ||||||||
| LastUpdateDate: | 03/15/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | 60841848 | WA | N | Allopathic & Osteopathic Physicians | Ophthalmology | 207W00000X | A141899 | CA | N | Allopathic & Osteopathic Physicians | Ophthalmology | 207W00000X | 13306A | WY | N | Allopathic & Osteopathic Physicians | Ophthalmology | 207W00000X | 33318 | NE | N | Allopathic & Osteopathic Physicians | Ophthalmology | 390200000X | TL.0005316 | CO | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207W00000X | 12382 | SD | Y | Allopathic & Osteopathic Physicians | Ophthalmology |
No ID Information.