Provider Demographics
NPI:1265489967
Name:BERNSTROM, MITCHEL L (MD)
Entity Type:Individual
Prefix:DR
First Name:MITCHEL
Middle Name:L
Last Name:BERNSTROM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:2055 KIMBALL AVE STE 400
Mailing Address - Street 2:
Mailing Address - City:WATERLOO
Mailing Address - State:IA
Mailing Address - Zip Code:50702-5047
Mailing Address - Country:US
Mailing Address - Phone:319-272-0000
Mailing Address - Fax:319-272-1329
Practice Address - Street 1:2055 KIMBALL AVE STE 400
Practice Address - Street 2:
Practice Address - City:WATERLOO
Practice Address - State:IA
Practice Address - Zip Code:50702
Practice Address - Country:US
Practice Address - Phone:319-272-0000
Practice Address - Fax:319-272-1329
Is Sole Proprietor?:No
Enumeration Date:2006-05-28
Last Update Date:2018-06-27
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IA25101207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA2029272Medicaid
IA47502Medicare PIN
IA2029272Medicaid