Provider Demographics
NPI:1023087434
Name:BERNAL, KENNETH R (DO)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:R
Last Name:BERNAL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2265 N LAKESHORE DR STE 101
Mailing Address - Street 2:
Mailing Address - City:ROCKWALL
Mailing Address - State:TX
Mailing Address - Zip Code:75087-3210
Mailing Address - Country:US
Mailing Address - Phone:972-771-2500
Mailing Address - Fax:972-722-4550
Practice Address - Street 1:2265 N LAKESHORE DR STE 101
Practice Address - Street 2:
Practice Address - City:ROCKWALL
Practice Address - State:TX
Practice Address - Zip Code:75087-3210
Practice Address - Country:US
Practice Address - Phone:972-771-2500
Practice Address - Fax:972-722-4550
Is Sole Proprietor?:No
Enumeration Date:2006-03-16
Last Update Date:2019-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH2245207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX121379506Medicaid
TX121379505Medicaid
TX1213379507Medicaid
TX8J1239Medicare ID - Type Unspecified
TX8G5444Medicare ID - Type UnspecifiedDALLAS CTY MEDICARE
TX1213379507Medicaid
TX121379506Medicaid
TX121379505Medicaid