Provider Demographics
NPI:1124009600
Name:TISDALE, BERNARD ALVAN (MD)
Entity Type:Individual
Prefix:
First Name:BERNARD
Middle Name:ALVAN
Last Name:TISDALE
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 1:1109 W MARSHALL ST
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23220-3835
Mailing Address - Country:US
Mailing Address - Phone:804-257-7337
Mailing Address - Fax:804-359-6898
Practice Address - Street 1:1109 W MARSHALL ST
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23220-3835
Practice Address - Country:US
Practice Address - Phone:804-257-7337
Practice Address - Fax:804-359-6898
Is Sole Proprietor?:No
Enumeration Date:2005-11-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01010402362085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA5866740Medicaid