Provider Demographics
NPI:1174554703
Name:BERGEN, DARA (RD)
Entity type:Individual
Prefix:
First Name:DARA
Middle Name:
Last Name:BERGEN
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11241 QUEENS BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:FOREST HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11375-5564
Mailing Address - Country:US
Mailing Address - Phone:718-544-0770
Mailing Address - Fax:718-261-2262
Practice Address - Street 1:11241 QUEENS BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:FOREST HILLS
Practice Address - State:NY
Practice Address - Zip Code:11375-5564
Practice Address - Country:US
Practice Address - Phone:718-544-0770
Practice Address - Fax:718-261-5522
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-05
Last Update Date:2009-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005450133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYBD5450OtherATLANTIS