Provider Demographics
NPI:1205835303
Name:BERNABE, PAUL (MD)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:
Last Name:BERNABE
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 1:54 HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:OSAGE BEACH
Mailing Address - State:MO
Mailing Address - Zip Code:65065-3050
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:304A E 4TH ST
Practice Address - Street 2:
Practice Address - City:ELDON
Practice Address - State:MO
Practice Address - Zip Code:65026-1808
Practice Address - Country:US
Practice Address - Phone:573-392-5654
Practice Address - Fax:573-392-5692
Is Sole Proprietor?:No
Enumeration Date:2005-07-20
Last Update Date:2008-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO118151207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO204005417Medicaid
MOP00232368OtherRAILROAD MEDICARE
G91995Medicare UPIN
MO204005417Medicaid