Healthcare Provider Details

I. General information

NPI: 1528045358
Provider Name (Legal Business Name): LOUIS MAXIMILIAN DIBERNARDO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/22/2005
Last Update Date: 06/26/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

974 W FOOTHILL BLVD
UPLAND CA
91786
US

IV. Provider business mailing address

974 W FOOTHILL BLVD
UPLAND CA
91786-3728
US

V. Phone/Fax

Practice location:
  • Phone: 909-981-2273
  • Fax:
Mailing address:
  • Phone: 909-981-2273
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA73815
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: