Provider Demographics
NPI:1982688321
Name:BERNEIKE, JOHN A (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:A
Last Name:BERNEIKE
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 1:1250 E 3900 S
Mailing Address - Street 2:SUITE 260
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84124-1348
Mailing Address - Country:US
Mailing Address - Phone:801-265-2000
Mailing Address - Fax:801-265-2008
Practice Address - Street 1:1250 E 3900 S
Practice Address - Street 2:SUITE 260
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84124-1348
Practice Address - Country:US
Practice Address - Phone:801-265-2000
Practice Address - Fax:801-265-2008
Is Sole Proprietor?:No
Enumeration Date:2005-11-30
Last Update Date:2021-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT3645941205207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT870617263004/D2710Medicaid
UTG85182Medicare UPIN
UT005716206Medicare PIN