Provider Demographics
NPI:1093876625
Name:BERGEL, ERNEST WALTER (MD)
Entity type:Individual
Prefix:DR
First Name:ERNEST
Middle Name:WALTER
Last Name:BERGEL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33 POND AVENUE
Mailing Address - Street 2:SUITE 104B
Mailing Address - City:BROOKLINE
Mailing Address - State:MA
Mailing Address - Zip Code:02445-7159
Mailing Address - Country:US
Mailing Address - Phone:617-739-1812
Mailing Address - Fax:
Practice Address - Street 1:33 POND AVENUE
Practice Address - Street 2:SUITE 104B
Practice Address - City:BROOKLINE
Practice Address - State:MA
Practice Address - Zip Code:02445-7159
Practice Address - Country:US
Practice Address - Phone:617-739-1812
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA262302084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MABEM07575OtherBLUE CROSS BLUE SHIELD
MA778278OtherTUFTS HEALTH PLAN
M07575Medicare ID - Type Unspecified
MA778278OtherTUFTS HEALTH PLAN