Provider Demographics
NPI:1972661569
Name:MERIZALDE, BERNARDO A (MD)
Entity Type:Individual
Prefix:DR
First Name:BERNARDO
Middle Name:A
Last Name:MERIZALDE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:600 GERMANTOWN PIKE
Mailing Address - Street 2:SUITE A
Mailing Address - City:LAFAYETTE HILL
Mailing Address - State:PA
Mailing Address - Zip Code:19444-1800
Mailing Address - Country:US
Mailing Address - Phone:610-238-9963
Mailing Address - Fax:610-238-0460
Practice Address - Street 1:600 GERMANTOWN PIKE
Practice Address - Street 2:SUITE A
Practice Address - City:LAFAYETTE HILL
Practice Address - State:PA
Practice Address - Zip Code:19444-1800
Practice Address - Country:US
Practice Address - Phone:610-238-9963
Practice Address - Fax:610-238-0460
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PAMD039662L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAB42108Medicare UPIN
PAB42108Medicare ID - Type Unspecified