Provider Demographics
NPI:1043466899
Name:BERGESON BARKDULL, JILL (MD)
Entity type:Individual
Prefix:DR
First Name:JILL
Middle Name:
Last Name:BERGESON BARKDULL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:830 N 2000 W
Mailing Address - Street 2:
Mailing Address - City:PLEASANT GROVE
Mailing Address - State:UT
Mailing Address - Zip Code:84062-4047
Mailing Address - Country:US
Mailing Address - Phone:801-756-3511
Mailing Address - Fax:801-443-1164
Practice Address - Street 1:830 N 2000 W
Practice Address - Street 2:
Practice Address - City:PLEASANT GROVE
Practice Address - State:UT
Practice Address - Zip Code:84062-4047
Practice Address - Country:US
Practice Address - Phone:801-756-1705
Practice Address - Fax:801-443-1164
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-12
Last Update Date:2013-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT57647571205207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT171564OtherPEHP
UT870293878OtherEMI HEALTH
UT107107195101OtherSELECT HEALTH
UT1043466899OtherALTIUS
UT1043466899OtherTRICARE
UT1043466899Medicaid
UT1126140OtherDESERET HEALTHCARE TRUST
UT171564OtherPEHP