Healthcare Provider Details

I. General information

NPI: 1083100234
Provider Name (Legal Business Name): BERNARDO LIBERATO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2018
Last Update Date: 07/10/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

80 JESSE HILL JR DR SE
ATLANTA GA
30303-3031
US

IV. Provider business mailing address

80 JESSE HILL JR DR SE
ATLANTA GA
30303-3031
US

V. Phone/Fax

Practice location:
  • Phone: 404-616-5169
  • Fax:
Mailing address:
  • Phone: 404-616-5169
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084V0102X
TaxonomyVascular Neurology Physician
License Number80990
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number80990
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: