Provider Demographics
NPI:1558658369
Name:BERGERSON, JOSEPH THOMAS (MD)
Entity type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:THOMAS
Last Name:BERGERSON
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 1:19829 N 27TH AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85027-4001
Mailing Address - Country:US
Mailing Address - Phone:623-879-6100
Mailing Address - Fax:
Practice Address - Street 1:269 S CANDY LN
Practice Address - Street 2:
Practice Address - City:COTTONWOOD
Practice Address - State:AZ
Practice Address - Zip Code:86326
Practice Address - Country:US
Practice Address - Phone:928-639-5588
Practice Address - Fax:928-639-5589
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-30
Last Update Date:2020-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ56349208M00000X
PAMD452537207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0015654460023Medicaid