Provider Demographics
NPI:1780655498
Name:BERNARD, JACQUELINE MAHER (MD)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:MAHER
Last Name:BERNARD
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 1:1673 MASON AVE
Mailing Address - Street 2:SUITE 305
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32117-5516
Mailing Address - Country:US
Mailing Address - Phone:386-274-7118
Mailing Address - Fax:386-274-6173
Practice Address - Street 1:1673 MASON AVE
Practice Address - Street 2:SUITE 305
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32117-5515
Practice Address - Country:US
Practice Address - Phone:386-274-7118
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-30
Last Update Date:2023-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 1032822085R0202X, 2085R0202X
WV234492085R0202X
SC332352085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL6G4SNOtherBLUE CROSS/BLUE SHIELD
EP428Medicare PIN