Provider Demographics
NPI:1548424823
Name:BERNARDEZ-FU, GRACE KIM (OD)
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:KIM
Last Name:BERNARDEZ-FU
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10701 SUDLEY MANOR DR
Mailing Address - Street 2:
Mailing Address - City:MANASSAS
Mailing Address - State:VA
Mailing Address - Zip Code:20109-2845
Mailing Address - Country:US
Mailing Address - Phone:703-365-0500
Mailing Address - Fax:
Practice Address - Street 1:10701 SUDLEY MANOR DR
Practice Address - Street 2:
Practice Address - City:MANASSAS
Practice Address - State:VA
Practice Address - Zip Code:20109-2845
Practice Address - Country:US
Practice Address - Phone:703-365-0500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-15
Last Update Date:2011-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007238152W00000X
VA0618001693152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist