Provider Demographics
NPI:1053756783
Name:BERGMAN, LEAH (DO)
Entity type:Individual
Prefix:DR
First Name:LEAH
Middle Name:
Last Name:BERGMAN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:175 E MAIN ST
Mailing Address - Street 2:STE 200
Mailing Address - City:HUNTINGTON
Mailing Address - State:NY
Mailing Address - Zip Code:11743-2981
Mailing Address - Country:US
Mailing Address - Phone:631-549-5700
Mailing Address - Fax:631-424-6759
Practice Address - Street 1:9105 FRANKLIN SQUARE DR
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21237-3930
Practice Address - Country:US
Practice Address - Phone:410-574-1330
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-08
Last Update Date:2020-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD87552207RC0000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program