Provider Demographics
NPI:1164599262
Name:DIBERNARDO, BARRY E (MD, PC)
Entity Type:Individual
Prefix:DR
First Name:BARRY
Middle Name:E
Last Name:DIBERNARDO
Suffix:
Gender:M
Credentials:MD, PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29 PARK ST
Mailing Address - Street 2:
Mailing Address - City:MONTCLAIR
Mailing Address - State:NJ
Mailing Address - Zip Code:07042-3407
Mailing Address - Country:US
Mailing Address - Phone:973-509-2000
Mailing Address - Fax:973-655-1228
Practice Address - Street 1:29 PARK ST
Practice Address - Street 2:
Practice Address - City:MONTCLAIR
Practice Address - State:NJ
Practice Address - Zip Code:07042-3407
Practice Address - Country:US
Practice Address - Phone:973-509-2000
Practice Address - Fax:973-655-1228
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-30
Last Update Date:2007-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA055909002086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJE97435Medicare UPIN
NJ686377Medicare ID - Type Unspecified