Provider Demographics
NPI:1225084445
Name:BERNARDO, ROSALEAH VICTORINO (MD)
Entity Type:Individual
Prefix:
First Name:ROSALEAH
Middle Name:VICTORINO
Last Name:BERNARDO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7008 MAPLE LN
Mailing Address - Street 2:
Mailing Address - City:HORACE
Mailing Address - State:ND
Mailing Address - Zip Code:58047-4713
Mailing Address - Country:US
Mailing Address - Phone:701-282-3929
Mailing Address - Fax:
Practice Address - Street 1:1406 6TH AVE N
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303-1900
Practice Address - Country:US
Practice Address - Phone:320-251-2700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-26
Last Update Date:2008-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD4117208000000X
MN36065208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
SDS42477Medicare PIN
F51044Medicare UPIN