Individual
DR. THEODORE J BERGSTROM
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
55 W TIETAN ST, WALLA WALLA, WA 99362-4445
(509) 525-3720
(509) 522-1578
Mailing address
55 W TIETAN ST, WALLA WALLA, WA 99362-4445
(509) 525-3720
(509) 522-1592
Taxonomy
Speciality
Code
Description
License number
State
208000000X
Pediatrics Physician
Primary
MD00022923
WA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
10041910
RAIL ROAD MEDICARE
WA
05
—
1007525
—
WA
05
—
152421
—
OR
01
—
40225
L&I
WA
Enumeration date
02/14/2006
Last updated
11/27/2007
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