Healthcare Provider Details

I. General information

NPI: 1891990743
Provider Name (Legal Business Name): PAUL JEROME BERNARD MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2007
Last Update Date: 10/28/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10700 MEDLOCK BRIDGE RD SUITE 102
DULUTH GA
30097-8456
US

IV. Provider business mailing address

10700 MEDLOCK BRIDGE RD SUITE 102
DULUTH GA
30097-8456
US

V. Phone/Fax

Practice location:
  • Phone: 678-691-5351
  • Fax: 770-685-1241
Mailing address:
  • Phone: 678-691-5351
  • Fax: 770-685-1241

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080P0205X
TaxonomyPediatric Endocrinology Physician
License Number2007015922
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code2080P0205X
TaxonomyPediatric Endocrinology Physician
License Number060045
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: