Provider Demographics
NPI:1164483699
Name:BERNABE, VICENTE R (DO)
Entity Type:Individual
Prefix:DR
First Name:VICENTE
Middle Name:R
Last Name:BERNABE
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 1:1191 MAGNOLIA AVE
Mailing Address - Street 2:SUITE D-152
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92879-3215
Mailing Address - Country:US
Mailing Address - Phone:951-777-6187
Mailing Address - Fax:951-777-6187
Practice Address - Street 1:1191 MAGNOLIA AVE
Practice Address - Street 2:STE D-152
Practice Address - City:CORONA
Practice Address - State:CA
Practice Address - Zip Code:92879-3215
Practice Address - Country:US
Practice Address - Phone:951-777-6187
Practice Address - Fax:951-777-6187
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-02
Last Update Date:2017-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A7405207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00AX74050Medicaid
CACJ885ZMedicare PIN
020A74050Medicare PIN
CA00AX74050Medicaid
CACK820AMedicare PIN