Healthcare Provider Details

I. General information

NPI: 1326057688
Provider Name (Legal Business Name): JOHANN V BERNARDO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/05/2006
Last Update Date: 11/16/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1708 YAKIMA AVE STE 110
TACOMA WA
98405-5307
US

IV. Provider business mailing address

1708 YAKIMA AVE STE 110
TACOMA WA
98405-5307
US

V. Phone/Fax

Practice location:
  • Phone: 253-627-9151
  • Fax: 253-591-8892
Mailing address:
  • Phone: 253-627-9151
  • Fax: 253-591-8892

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD00037004
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: