Provider Demographics
NPI:1780757195
Name:BERGTRAUM, MARCIA P (MD)
Entity type:Individual
Prefix:DR
First Name:MARCIA
Middle Name:P
Last Name:BERGTRAUM
Suffix:
Gender:F
Credentials:MD
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Mailing Address - Street 1:3003 NEW HYDE PARK RD
Mailing Address - Street 2:SUITE 204
Mailing Address - City:NEW HYDE PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11042-1214
Mailing Address - Country:US
Mailing Address - Phone:516-488-2323
Mailing Address - Fax:516-488-7585
Practice Address - Street 1:3003 NEW HYDE PARK RD
Practice Address - Street 2:SUITE 204
Practice Address - City:NEW HYDE PARK
Practice Address - State:NY
Practice Address - Zip Code:11042-1214
Practice Address - Country:US
Practice Address - Phone:516-488-2323
Practice Address - Fax:516-488-7585
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-15
Last Update Date:2007-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NY1288972084N0402X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0402XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology with Special Qualifications in Child Neurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYB19397Medicare UPIN