Provider Demographics
NPI:1578580536
Name:CANZONERI, BERNARD JOSEPH (MD)
Entity Type:Individual
Prefix:
First Name:BERNARD
Middle Name:JOSEPH
Last Name:CANZONERI
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 1:5501 WILLOW CREEK DR
Mailing Address - Street 2:SUITE 202
Mailing Address - City:SPRINGDALE
Mailing Address - State:AR
Mailing Address - Zip Code:72762-8704
Mailing Address - Country:US
Mailing Address - Phone:479-443-4500
Mailing Address - Fax:479-249-6910
Practice Address - Street 1:5501 WILLOW CREEK DR
Practice Address - Street 2:SUITE 202
Practice Address - City:SPRINGDALE
Practice Address - State:AR
Practice Address - Zip Code:72762-8704
Practice Address - Country:US
Practice Address - Phone:479-443-4500
Practice Address - Fax:479-249-6910
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-16
Last Update Date:2020-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2006-00926207V00000X
LAMD025689208600000X
ARE7297207VM0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VM0101XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyMaternal & Fetal Medicine
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1040959Medicaid
MS029287798Medicaid
NC1420ROtherBCBS
MS029287798Medicaid
LA4J588F600Medicare ID - Type Unspecified
LA4J5887061Medicare PIN
LA4J588Medicare PIN