Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2080P0208X | Pediatric Infectious Diseases | G52916 | CA |
NPI | 1316025497 |
---|---|
Provider Name | Randy E. Bergen |
First Address | Oakland, CA 94612-3429 |
Second Address | Walnut Creek, CA 94596-5318 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 02/11/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
00G529160 | (05) | CA |
F41030 | (02) |