Provider Demographics
NPI:1053302943
Name:BERNARDO, PETER AUGUSTO (MD)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:AUGUSTO
Last Name:BERNARDO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 BELLEVUE ST SE
Mailing Address - Street 2:SUITE 230
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97301-3819
Mailing Address - Country:US
Mailing Address - Phone:503-585-6586
Mailing Address - Fax:503-371-4180
Practice Address - Street 1:700 BELLEVUE ST SE
Practice Address - Street 2:SUITE 230
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-3819
Practice Address - Country:US
Practice Address - Phone:503-585-6586
Practice Address - Fax:503-371-4180
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR17631208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR044458Medicaid
OR044458Medicaid