=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164599262
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BARRY E DIBERNARDO MD, P.C.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/30/2006
-----------------------------------------------------
Last Update Date | 11/09/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 29 PARK ST
-----------------------------------------------------
City | MONTCLAIR
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07042-3407
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-509-2000
-----------------------------------------------------
Fax | 973-655-1228
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 29 PARK ST
-----------------------------------------------------
City | MONTCLAIR
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07042-3407
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-509-2000
-----------------------------------------------------
Fax | 973-655-1228
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2086S0122X
-----------------------------------------------------
Taxonomy Name | Plastic and Reconstructive Surgery Physician
-----------------------------------------------------
License Number | 25MA05590900
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------