Provider Demographics
NPI:1376672865
Name:TREJO, BERNIE RAUL (OD)
Entity Type:Individual
Prefix:DR
First Name:BERNIE
Middle Name:RAUL
Last Name:TREJO
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2680 E VALENCIA RD STE 188
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85706-5962
Mailing Address - Country:US
Mailing Address - Phone:520-889-7766
Mailing Address - Fax:520-889-2306
Practice Address - Street 1:2680 E VALENCIA RD STE 188
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85706-5962
Practice Address - Country:US
Practice Address - Phone:520-889-7766
Practice Address - Fax:520-889-2306
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ664152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZT42220Medicare UPIN