Provider Demographics
NPI:1457937187
Name:BERGSTROM, TAYLOR KRISTINE
Entity type:Individual
Prefix:
First Name:TAYLOR
Middle Name:KRISTINE
Last Name:BERGSTROM
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1075 WHITLOCK AVE SW STE I
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30064-1996
Mailing Address - Country:US
Mailing Address - Phone:678-215-1882
Mailing Address - Fax:
Practice Address - Street 1:3280 HOWELL MILL RD NW STE 243
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30327-4100
Practice Address - Country:US
Practice Address - Phone:678-215-1882
Practice Address - Fax:561-548-1743
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-23
Last Update Date:2025-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL390200000X
GAPOD305017213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Multi-Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program