Provider Demographics
NPI:1457301384
Name:BERNSTEIN, JACK M (MD)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:M
Last Name:BERNSTEIN
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 1:101 S SAN MATEO DR
Mailing Address - Street 2:
Mailing Address - City:SAN MATEO
Mailing Address - State:CA
Mailing Address - Zip Code:94401-3840
Mailing Address - Country:US
Mailing Address - Phone:650-942-7071
Mailing Address - Fax:
Practice Address - Street 1:101 S SAN MATEO DR
Practice Address - Street 2:
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94401-3819
Practice Address - Country:US
Practice Address - Phone:650-942-7071
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC28238207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA33562Medicare UPIN
CA00C282380Medicare ID - Type Unspecified