Provider Demographics
NPI:1285049940
Name:BERGMAN, CORY (MD)
Entity type:Individual
Prefix:
First Name:CORY
Middle Name:
Last Name:BERGMAN
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 1:2800 3RD ST
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57701-7374
Mailing Address - Country:US
Mailing Address - Phone:605-719-3110
Mailing Address - Fax:605-341-0278
Practice Address - Street 1:2800 3RD ST
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57701-7374
Practice Address - Country:US
Practice Address - Phone:605-719-3110
Practice Address - Fax:605-341-0278
Is Sole Proprietor?:No
Enumeration Date:2014-06-21
Last Update Date:2021-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60841848207W00000X
CAA141899207W00000X
WY13306A207W00000X
NE33318207W00000X
COTL.0005316390200000X
SD12382207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program