1174554703 NPI number — DARA BERGEN RD

Table of content: DARA BERGEN RD (NPI 1174554703)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174554703 NPI number — DARA BERGEN RD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BERGEN
Provider First Name:
DARA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
RD
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:
1174554703
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/02/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11241 QUEENS BLVD
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
FOREST HILLS
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11375-5564
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
718-544-0770
Provider Business Mailing Address Fax Number:
718-261-2262

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11241 QUEENS BLVD
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
FOREST HILLS
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11375-5564
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-544-0770
Provider Business Practice Location Address Fax Number:
718-261-5522
Provider Enumeration Date:
07/05/2006

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: 133V00000X , with the licence number:  005450 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: BD5450 . This is a "ATLANTIS" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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