Provider Demographics
NPI:1942225016
Name:BERNAL, SAMUEL DEQUINA (MD, PHD)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:DEQUINA
Last Name:BERNAL
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20000 CALVERT ST
Mailing Address - Street 2:
Mailing Address - City:WOODLAND HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91367-3814
Mailing Address - Country:US
Mailing Address - Phone:818-347-4212
Mailing Address - Fax:818-347-4040
Practice Address - Street 1:200 MEDICAL PLAZA
Practice Address - Street 2:#365
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90095
Practice Address - Country:US
Practice Address - Phone:310-825-0631
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG75613207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G756130OtherMEDICAL PPIN #
CAA56549Medicare UPIN
CAWG75613AMedicare ID - Type UnspecifiedPPIN #