Basic Information
| Provider Information | |||||||||
| NPI: | 1467575654 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BERGESON | ||||||||
| FirstName: | JEFFREY | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10470 OLD PLACERVILLE RD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958272539 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8004700071 | ||||||||
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| Practice Location | |||||||||
| Address1: | 11795 EDUCATION ST | ||||||||
| Address2: | SUITE 110 | ||||||||
| City: | AUBURN | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956022454 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5308866820 | ||||||||
| FaxNumber: | 5308866821 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/10/2007 | ||||||||
| LastUpdateDate: | 05/12/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 20A9815 | CA | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 00AX98150 | 05 | CA | MEDICAID |