Healthcare Provider Details

I. General information

NPI: 1295964971
Provider Name (Legal Business Name): JOHNATHAN ALEXANDER BERNARD MD, MPH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2009
Last Update Date: 11/10/2020
Certification Date: 11/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24600 MILLSTREAM DRIVE SUITE 380
ALDIE VA
20105-5686
US

IV. Provider business mailing address

PO BOX 75868
BALTIMORE MD
21275-4095
US

V. Phone/Fax

Practice location:
  • Phone: 703-810-5241
  • Fax: 571-407-5689
Mailing address:
  • Phone: 703-810-5204
  • Fax: 703-810-5411

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number0101258391
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: