Provider Demographics
NPI:1255306817
Name:BERNAL, HUMBERTO (MD)
Entity Type:Individual
Prefix:
First Name:HUMBERTO
Middle Name:
Last Name:BERNAL
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 1:18100 OAKWOOD BLVD
Mailing Address - Street 2:#203
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48124-4071
Mailing Address - Country:US
Mailing Address - Phone:313-336-7400
Mailing Address - Fax:
Practice Address - Street 1:18100 OAKWOOD BLVD
Practice Address - Street 2:STE 203
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124-4085
Practice Address - Country:US
Practice Address - Phone:313-336-7400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-17
Last Update Date:2017-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301044715207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIHB044715OtherBCBS
MI3515265Medicaid
MI383438259OtherCOMMERCIAL
MIHB044715OtherBCBS
MI0P16500001Medicare PIN