Provider Demographics
NPI:1063854453
Name:BERNAL, MATEO D (DOM)
Entity Type:Individual
Prefix:
First Name:MATEO
Middle Name:D
Last Name:BERNAL
Suffix:
Gender:M
Credentials:DOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1502 E LAS CRUCES AVE
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88001-2636
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1605 S MAIN ST
Practice Address - Street 2:BLDG A
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88005-3124
Practice Address - Country:US
Practice Address - Phone:575-541-5660
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-25
Last Update Date:2013-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1105171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist