Provider Demographics
NPI:1871664714
Name:BERNACKI, WALTER LANG (MD)
Entity Type:Individual
Prefix:DR
First Name:WALTER
Middle Name:LANG
Last Name:BERNACKI
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 1:1085 E. JOHNSTOWN RD.
Mailing Address - Street 2:
Mailing Address - City:GAHANNA
Mailing Address - State:OH
Mailing Address - Zip Code:43230
Mailing Address - Country:US
Mailing Address - Phone:614-682-5095
Mailing Address - Fax:614-891-6533
Practice Address - Street 1:1085 E. JOHNSTOWN RD.
Practice Address - Street 2:
Practice Address - City:GAHANNA
Practice Address - State:OH
Practice Address - Zip Code:43230
Practice Address - Country:US
Practice Address - Phone:614-682-5095
Practice Address - Fax:614-891-6533
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-13
Last Update Date:2023-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35071567B174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2319244Medicaid
OHH62525Medicare UPIN
OH4084291Medicare PIN