Provider Demographics
NPI:1073725354
Name:BERNACCHIA, DEAN H (MD)
Entity Type:Individual
Prefix:
First Name:DEAN
Middle Name:H
Last Name:BERNACCHIA
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 1:4366 LAKEVIEW GLEN DRIVE
Mailing Address - Street 2:
Mailing Address - City:MEDINA
Mailing Address - State:OH
Mailing Address - Zip Code:44256-6513
Mailing Address - Country:US
Mailing Address - Phone:330-721-2774
Mailing Address - Fax:
Practice Address - Street 1:4366 LAKEVIEW GLEN DRIVE
Practice Address - Street 2:
Practice Address - City:MEDINA
Practice Address - State:OH
Practice Address - Zip Code:44256-6513
Practice Address - Country:US
Practice Address - Phone:330-721-2774
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35025014B208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0406868Medicaid
A73384Medicare UPIN
OH0406868Medicaid