Provider Demographics
NPI:1083676662
Name:HANNAM, BERNARD RAY (DO)
Entity Type:Individual
Prefix:DR
First Name:BERNARD
Middle Name:RAY
Last Name:HANNAM
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 1:455 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92868-3835
Mailing Address - Country:US
Mailing Address - Phone:714-532-8644
Mailing Address - Fax:714-289-4508
Practice Address - Street 1:455 S MAIN ST
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-3835
Practice Address - Country:US
Practice Address - Phone:714-532-8644
Practice Address - Fax:714-289-4508
Is Sole Proprietor?:No
Enumeration Date:2006-04-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A48692080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1083676662Medicare ID - Type Unspecified