Healthcare Provider Details

I. General information

NPI: 1861856932
Provider Name (Legal Business Name): MATTHEW BERNETICH D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2016
Last Update Date: 09/26/2023
Certification Date: 10/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1310 SOUTHERN AVE SE
WASHINGTON DC
20032-4623
US

IV. Provider business mailing address

1310 SOUTHERN AVE SE
WASHINGTON DC
20032-4623
US

V. Phone/Fax

Practice location:
  • Phone: 202-574-5323
  • Fax:
Mailing address:
  • Phone: 202-574-5323
  • Fax: 202-574-5225

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberDO034777
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: