Provider Demographics
NPI:1518952431
Name:BERMUDEZ, MINDA (MD)
Entity Type:Individual
Prefix:
First Name:MINDA
Middle Name:
Last Name:BERMUDEZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:451 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:PA
Mailing Address - Zip Code:18704-5802
Mailing Address - Country:US
Mailing Address - Phone:570-283-0205
Mailing Address - Fax:570-283-0199
Practice Address - Street 1:451 3RD AVE
Practice Address - Street 2:
Practice Address - City:KINGSTON
Practice Address - State:PA
Practice Address - Zip Code:18704-5802
Practice Address - Country:US
Practice Address - Phone:570-283-0205
Practice Address - Fax:570-283-0199
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD044051-L2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
F42064Medicare UPIN
PA052409Medicare ID - Type Unspecified