Provider Demographics
NPI:1790970648
Name:TEGTMEIER, BERNARD RICHARD (PHD)
Entity Type:Individual
Prefix:DR
First Name:BERNARD
Middle Name:RICHARD
Last Name:TEGTMEIER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4312 FIR AVE
Mailing Address - Street 2:
Mailing Address - City:SEAL BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90740-2905
Mailing Address - Country:US
Mailing Address - Phone:562-493-6132
Mailing Address - Fax:
Practice Address - Street 1:1500 DUARTE RD
Practice Address - Street 2:
Practice Address - City:DUARTE
Practice Address - State:CA
Practice Address - Zip Code:91010-3012
Practice Address - Country:US
Practice Address - Phone:626-301-8225
Practice Address - Fax:626-301-8954
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-12
Last Update Date:2007-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADRI39247ZC0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247ZC0005XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyClinical Laboratory Director, Non-physician