Provider Demographics
NPI:1457441263
Name:EXCELLENT, BERNY (MD)
Entity Type:Individual
Prefix:
First Name:BERNY
Middle Name:
Last Name:EXCELLENT
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 1:1839 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33713-8900
Mailing Address - Country:US
Mailing Address - Phone:727-322-1054
Mailing Address - Fax:727-322-2725
Practice Address - Street 1:1839 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:SAINT PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33713-8900
Practice Address - Country:US
Practice Address - Phone:727-322-1054
Practice Address - Fax:727-483-5441
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2013-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0058124101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL053002600Medicaid
FL15154YMedicare ID - Type UnspecifiedMEDICARE B
FL053002600Medicaid