Healthcare Provider Details

I. General information

NPI: 1699864132
Provider Name (Legal Business Name): BERNARD L. PACELLA JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/12/2006
Last Update Date: 01/20/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 E 61ST ST APT 4C
NEW YORK NY
10021-8184
US

IV. Provider business mailing address

15 BARNES RD
MANORVILLE NY
11949-2002
US

V. Phone/Fax

Practice location:
  • Phone: 212-486-5000
  • Fax: 631-657-5456
Mailing address:
  • Phone: 631-882-4025
  • Fax: 631-657-5456

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YS0123X
TaxonomyFacial Plastic Surgery Physician
License Number195401-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: