Provider Demographics
NPI:1235526591
Name:BERGLUND, DEREK
Entity type:Individual
Prefix:
First Name:DEREK
Middle Name:
Last Name:BERGLUND
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:549 MANCHESTER CT
Mailing Address - Street 2:
Mailing Address - City:PISCATAWAY
Mailing Address - State:NJ
Mailing Address - Zip Code:08854-6221
Mailing Address - Country:US
Mailing Address - Phone:701-226-1806
Mailing Address - Fax:
Practice Address - Street 1:81 VERONICA AVE STE 205
Practice Address - Street 2:
Practice Address - City:SOMERSET
Practice Address - State:NJ
Practice Address - Zip Code:08873-3491
Practice Address - Country:US
Practice Address - Phone:732-640-5316
Practice Address - Fax:800-689-2361
Is Sole Proprietor?:No
Enumeration Date:2015-04-23
Last Update Date:2024-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT142708208600000X
390200000X
NJ25MA11864000208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program