Healthcare Provider Details

I. General information

NPI: 1528646775
Provider Name (Legal Business Name): SETH EDWARD BERNACKI DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/30/2021
Last Update Date: 05/12/2026
Certification Date: 05/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4513 WILLIAMS DR
GEORGETOWN TX
78633-1302
US

IV. Provider business mailing address

4513 WILLIAMS DR
GEORGETOWN TX
78633-1302
US

V. Phone/Fax

Practice location:
  • Phone: 512-930-3909
  • Fax: 512-869-5868
Mailing address:
  • Phone: 512-930-3909
  • Fax: 512-869-5868

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License NumberW1383
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number109700
License Number StateGA
# 3
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberW1383
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: