Healthcare Provider Details

I. General information

NPI: 1154426179
Provider Name (Legal Business Name): MARINETTE GONZALES BERNARDO MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2006
Last Update Date: 02/01/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1721 E HAMMER LN STE A
STOCKTON CA
95210-4124
US

IV. Provider business mailing address

PO BOX 779
STOCKTON CA
95201-0779
US

V. Phone/Fax

Practice location:
  • Phone: 209-373-2829
  • Fax:
Mailing address:
  • Phone: 209-373-2814
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA96571
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: