1700807906 NPI number — J. DUSTIN BERNARD, D.O., MEDICAL CORPORATION

Table of content: (NPI 1700807906)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700807906 NPI number — J. DUSTIN BERNARD, D.O., MEDICAL CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
J. DUSTIN BERNARD, D.O., MEDICAL CORPORATION
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1700807906
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/29/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 12338
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN LUIS OBISPO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
93406-2338
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
805-546-9911
Provider Business Mailing Address Fax Number:
805-546-9933

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2074 PARKER ST
Provider Second Line Business Practice Location Address:
SUITE 120
Provider Business Practice Location Address City Name:
SAN LUIS OBISPO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93401-5052
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
805-546-9911
Provider Business Practice Location Address Fax Number:
805-546-9933
Provider Enumeration Date:
07/22/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BERNARD
Authorized Official First Name:
JEANNE
Authorized Official Middle Name:
DUSTIN
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
805-546-9911

Provider Taxonomy Codes

  • Taxonomy code: 207RE0101X , with the licence number:  2414859 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: C2414859 . This is a "STATE DEPT OF CORPORATIONS NUMBER" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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