Provider Demographics
NPI:1184649477
Name:GUILLERMO BERNAL, MD
Entity Type:Organization
Organization Name:GUILLERMO BERNAL, MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GUILLERMO
Authorized Official - Middle Name:
Authorized Official - Last Name:BERNAL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:302-875-9355
Mailing Address - Street 1:646 N DUAL HWY
Mailing Address - Street 2:
Mailing Address - City:SEAFORD
Mailing Address - State:DE
Mailing Address - Zip Code:19973-1756
Mailing Address - Country:US
Mailing Address - Phone:302-628-2687
Mailing Address - Fax:302-628-3791
Practice Address - Street 1:405 N CENTRAL AVE STE A
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:DE
Practice Address - Zip Code:19956-1104
Practice Address - Country:US
Practice Address - Phone:302-875-9355
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC10001671174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE0000186501Medicaid
DE0000186501Medicaid
DEB66274Medicare UPIN