Provider Demographics
NPI:1538168679
Name:BERGNER, MICHELLE R (MD)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:R
Last Name:BERGNER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:R
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5300 N INDEPENDENCE AVE
Mailing Address - Street 2:280
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73112-5556
Mailing Address - Country:US
Mailing Address - Phone:580-233-1100
Mailing Address - Fax:580-548-1434
Practice Address - Street 1:601 W GARRIOTT RD
Practice Address - Street 2:
Practice Address - City:ENID
Practice Address - State:OK
Practice Address - Zip Code:73701-5524
Practice Address - Country:US
Practice Address - Phone:580-233-1100
Practice Address - Fax:580-548-1434
Is Sole Proprietor?:No
Enumeration Date:2005-07-20
Last Update Date:2018-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK23956207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200033320AMedicaid
OKP00262612OtherRR MEDICARE PTAN
OK242421506Medicare PIN
I09820Medicare UPIN