Provider Demographics
NPI:1720181910
Name:BERNARD, GARY C (MD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:C
Last Name:BERNARD
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 1:1996 KINGSLEY AVE
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32073-4442
Mailing Address - Country:US
Mailing Address - Phone:904-276-5700
Mailing Address - Fax:904-272-1474
Practice Address - Street 1:1996 KINGSLEY AVE
Practice Address - Street 2:
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073-4442
Practice Address - Country:US
Practice Address - Phone:904-276-5700
Practice Address - Fax:904-272-1474
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-06
Last Update Date:2019-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME-0069445207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL225324OtherAVMED ID NUMBER
FL651139585OtherFEDRERAL TAX ID NUMBER
FL225324OtherAVMED ID NUMBER
FL651139585OtherFEDRERAL TAX ID NUMBER