1306018148 NPI number — DIANE E BERGERON NP

Table of content: DIANE E BERGERON NP (NPI 1306018148)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306018148 NPI number — DIANE E BERGERON NP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BERGERON
Provider First Name:
DIANE
Provider Middle Name:
E
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
NP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1306018148
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/06/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 8307
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
THE WOODLANDS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77387-8307
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
281-296-8788
Provider Business Mailing Address Fax Number:
281-419-1291

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1111 MEDICAL PLAZA DR
Provider Second Line Business Practice Location Address:
250
Provider Business Practice Location Address City Name:
THE WOODLANDS
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77380-3240
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
281-296-8788
Provider Business Practice Location Address Fax Number:
281-419-1291
Provider Enumeration Date:
04/01/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LA2200X , with the licence number:  626794 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 193009102 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 154240902 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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