Provider Demographics
NPI:1679557367
Name:BERGSTROM, RICHARD T (MD)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:T
Last Name:BERGSTROM
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 1:3305 PLACER ST
Mailing Address - Street 2:STE A
Mailing Address - City:REDDING
Mailing Address - State:CA
Mailing Address - Zip Code:96001-2364
Mailing Address - Country:US
Mailing Address - Phone:530-243-3687
Mailing Address - Fax:530-243-3383
Practice Address - Street 1:3305 PLACER ST
Practice Address - Street 2:STE A
Practice Address - City:REDDING
Practice Address - State:CA
Practice Address - Zip Code:96001-2364
Practice Address - Country:US
Practice Address - Phone:530-243-3687
Practice Address - Fax:530-243-3383
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-06
Last Update Date:2012-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA80467207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A804670Medicaid
CA00A804670Medicare ID - Type Unspecified
CA00A804670Medicaid
GAP00114242Medicare PIN