Healthcare Provider Details

I. General information

NPI: 1780104943
Provider Name (Legal Business Name): ANDREW B BERNALES MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2017
Last Update Date: 06/02/2022
Certification Date: 06/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

402 N VAUGHAN DR
BRUSLY LA
70719-2225
US

IV. Provider business mailing address

PO BOX 19658
SPRINGFIELD IL
62794-9658
US

V. Phone/Fax

Practice location:
  • Phone: 225-448-5321
  • Fax: 225-448-5321
Mailing address:
  • Phone: 217-545-8000
  • Fax: 217-545-4779

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number324080
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number125069861
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: