Provider Demographics
NPI:1265787253
Name:DOUGLAS, BERNADETTE POLITE
Entity type:Individual
Prefix:MRS
First Name:BERNADETTE
Middle Name:POLITE
Last Name:DOUGLAS
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:BERNADETTE
Other - Middle Name:CYNTHIA
Other - Last Name:POLITE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1522 E 59TH ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11234-4106
Mailing Address - Country:US
Mailing Address - Phone:718-531-5343
Mailing Address - Fax:718-531-5343
Practice Address - Street 1:1522 E 59TH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11234-4106
Practice Address - Country:US
Practice Address - Phone:718-531-5343
Practice Address - Fax:718-531-5343
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-17
Last Update Date:2012-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY352520911174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist