MEDICARE: DAVID L. BERNDT DO PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QP2300X	Primary Care Clinic/Center	OS3372	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	81878	OTHER	FL	BCBS

General Provider Information

NPI Number	:	1740573179
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DAVID L. BERNDT DO PA

Provider Business Mailing Address
First Line	:	5930 SW 64 AVE
Second Line	:
City	:	DAVIE
State	:	FL
Zip	:	33314
Country	:	US
Telephone Number	:	954-791-7101
Fax Number	:	954-791-2521

Provider Business Practice Location Address
First Line	:	5930 SW 64TH AVE
Second Line	:
City	:	DAVIE
State	:	FL
Zip	:	33314-7116
Country	:	US
Telephone Number	:	954-791-7101
Fax Number	:	954-791-2521

Authorized Official
Title or Position	:	MEDICAL ASSISTANT
Name	:	JENNY MARTINEZ
Credential	:
Telephone Number	:	954-791-7101

Provider Enumeration Date	:	05/18/2011
Last Update Date	:	05/18/2011

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