Provider Demographics
NPI:1003895004
Name:BERMUDEZ, RENE (DO)
Entity Type:Individual
Prefix:
First Name:RENE
Middle Name:
Last Name:BERMUDEZ
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1099 MEDICAL CENTER DR STE 201
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28401-7346
Mailing Address - Country:US
Mailing Address - Phone:910-251-9944
Mailing Address - Fax:910-763-4666
Practice Address - Street 1:720 JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:WHITEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28472-3706
Practice Address - Country:US
Practice Address - Phone:910-251-9944
Practice Address - Fax:910-763-4666
Is Sole Proprietor?:No
Enumeration Date:2006-01-10
Last Update Date:2021-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2005-00626207ND0101X, 207N00000X
NC200500626207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND5900976Medicaid
OK100749090BMedicaid
NCNC6886AOtherMEDICARE PTAN, INDIVIDUAL
NC232009OtherMEDICARE PTAN, GROUP
OK100749090BMedicaid
OH2041234Medicare PIN
NC232009OtherMEDICARE PTAN, GROUP