Provider Demographics
NPI:1710027560
Name:BERNARD, TERESA I
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:
Last Name:BERNARD
Suffix:I
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:414 OLD HARD RD STE 104
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32003-3406
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:414 OLD HARD RD STE 104
Practice Address - Street 2:
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32003-3406
Practice Address - Country:US
Practice Address - Phone:904-269-6400
Practice Address - Fax:904-269-6410
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-08
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME46372207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL6957412OtherCIGNA INSURANCE
FLD52069Medicare UPIN