Basic Information
| Provider Information | |||||||||
| NPI: | 1750310231 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BERGMAN | ||||||||
| FirstName: | MICHELE | ||||||||
| MiddleName: | DIAHANN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BRATHWAITE | ||||||||
| OtherFirstName: | MICHELE | ||||||||
| OtherMiddleName: | DIAHANN | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D, | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 350 JOHN MUIR PKWY STE 140 | ||||||||
| Address2: | |||||||||
| City: | BRENTWOOD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945135190 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9255132483 | ||||||||
| FaxNumber: | 9255138226 | ||||||||
| Practice Location | |||||||||
| Address1: | 1120 2ND ST | ||||||||
| Address2: | |||||||||
| City: | BRENTWOOD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945132234 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9255132483 | ||||||||
| FaxNumber: | 9255134957 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/30/2006 | ||||||||
| LastUpdateDate: | 12/13/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | A77659 | CA | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
No ID Information.