1659453959 NPI number — DR. KIM LEE BERGERON-DUNCAN O.D.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659453959 NPI number — DR. KIM LEE BERGERON-DUNCAN O.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BERGERON-DUNCAN
Provider First Name:
KIM
Provider Middle Name:
LEE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
O.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BERGERON
Provider Other First Name:
KIM
Provider Other Middle Name:
LEE
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
O.D.
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1659453959
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
237 MEYER RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TORRINGTON
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06790-2806
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
860-489-4212
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
110 HOPMEADOW ST
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
WEATOGUE
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06089-9407
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-658-1704
Provider Business Practice Location Address Fax Number:
860-651-9966
Provider Enumeration Date:
10/19/2006

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: 152W00000X , with the licence number:  2596 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: CT2596 . This is a "EYEMED" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 090002596CT04 . This is a "BLUE CROSS/BLUE SHIELD" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: CT2596 . This is a "SUPERIOR VISION" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 2V5840 . This is a "HEALTHNET" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 1811978 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 259600 . This is a "CONNECTICARE" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 5799268 . This is a "CIGNA" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 9431179 . This is a "PHCS" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".




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