Provider Demographics
NPI:1467408682
Name:BERNDT, JACK E (MD)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:E
Last Name:BERNDT
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 1:1715 SW CHANDLER AVE
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97702-3615
Mailing Address - Country:US
Mailing Address - Phone:541-588-5620
Mailing Address - Fax:888-625-0286
Practice Address - Street 1:1715 SW CHANDLER AVE
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97702-3615
Practice Address - Country:US
Practice Address - Phone:541-588-5620
Practice Address - Fax:888-625-0286
Is Sole Proprietor?:No
Enumeration Date:2006-05-26
Last Update Date:2022-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD25340174400000X, 208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR022708Medicaid
OR022708Medicaid
R165090Medicare PIN