Provider Demographics
NPI:1861478588
Name:BERNARDY, MARK OTTO (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:OTTO
Last Name:BERNARDY
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 1:1031 JIMSON DR SE
Mailing Address - Street 2:
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30013-2064
Mailing Address - Country:US
Mailing Address - Phone:800-879-6274
Mailing Address - Fax:678-342-2547
Practice Address - Street 1:1031 JIMSON DR SE
Practice Address - Street 2:
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30013-2064
Practice Address - Country:US
Practice Address - Phone:800-879-6274
Practice Address - Fax:678-342-2547
Is Sole Proprietor?:No
Enumeration Date:2005-12-15
Last Update Date:2008-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0285022085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00256142OtherRR MEDICARE
GA30BDMLHMedicare ID - Type Unspecified
GAE87628Medicare UPIN