Provider Demographics
NPI:1306906771
Name:BERGAMO, NICOLE (OD)
Entity type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:
Last Name:BERGAMO
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11550 RIDGELINE DR UNIT 106
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80921-3953
Mailing Address - Country:US
Mailing Address - Phone:719-636-2020
Mailing Address - Fax:719-354-4071
Practice Address - Street 1:11550 RIDGELINE DR UNIT 106
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80921-3953
Practice Address - Country:US
Practice Address - Phone:719-636-2020
Practice Address - Fax:719-354-4071
Is Sole Proprietor?:No
Enumeration Date:2006-12-08
Last Update Date:2024-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2166152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO478588Medicare ID - Type Unspecified
COU84073Medicare UPIN