| Doctor Name: | DR. KENNETH ROBERT BERGMAN |
| NPI Number: | 1013912252 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | M.D. |
| License Number: | 0101025702 |
| Business Practice Address: | 13890 Braddock Rd Ste 206 Centreville, VA - 201212437 |
| Business Phone Number: | 7032632333 |
| Business Fax Number: | 7032630361 |
| Mailing Address: | 13890 Braddock Rd, Ste 206 CENTREVILLE |
| State: | VA |
| Postal Code: | 201212437 |
| Phone Number: | 7032632333 |
| Fax Number: | 7032630361 |
| NPI Enumeration Date: | 06/15/2005 |
| NPI Last Update Date: | 07/08/2007 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | 03/17/2006 |
| NPI Reactivation Date: | 03/31/2006 |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 207KA0200X |
| License Number: | 0101025702 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | VA |
| Taxonomy Type: | Allopathic & Osteopathic Physicians |
| Taxonomy Classification: | Allergy & Immunology |
| Taxonomy Specialization: | Allergy |
| Taxonomy Definition: | |