Basic Information
| Provider Information | |||||||||
| NPI: | 1760454391 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BERGEN | ||||||||
| FirstName: | EDWARD | ||||||||
| MiddleName: | CARL | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 122152 | ||||||||
| Address2: | DEPT 2152 | ||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 753122152 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3374942772 | ||||||||
| FaxNumber: | 3374942928 | ||||||||
| Practice Location | |||||||||
| Address1: | 1717 OAK PARK BLVD FL 2 | ||||||||
| Address2: | |||||||||
| City: | LAKE CHARLES | ||||||||
| State: | LA | ||||||||
| PostalCode: | 706018990 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3374943278 | ||||||||
| FaxNumber: | 3374943240 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/07/2006 | ||||||||
| LastUpdateDate: | 03/25/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/25/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RI0011X | DO000438 | LA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology |
No ID Information.