Provider Demographics
NPI:1356317283
Name:DESPRES, BERNARD THOMAS (DO)
Entity Type:Individual
Prefix:
First Name:BERNARD
Middle Name:THOMAS
Last Name:DESPRES
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1925 MIZELL AVE
Mailing Address - Street 2:STE 104
Mailing Address - City:WINTER PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32792
Mailing Address - Country:US
Mailing Address - Phone:407-657-4407
Mailing Address - Fax:407-657-4669
Practice Address - Street 1:1925 MIZELL AVE
Practice Address - Street 2:STE 104
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32792
Practice Address - Country:US
Practice Address - Phone:407-657-4407
Practice Address - Fax:407-657-4669
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-28
Last Update Date:2010-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS0005626207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL052247300Medicaid
E80143Medicare UPIN
FL052247300Medicaid