Provider Demographics
NPI:1649361031
Name:BERNERO, JOHN R (DO)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:R
Last Name:BERNERO
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 1:1680 E. SHORE DR.
Mailing Address - Street 2:
Mailing Address - City:CULVER
Mailing Address - State:IN
Mailing Address - Zip Code:46511
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1680 E. SHORE DR.
Practice Address - Street 2:
Practice Address - City:CULVER
Practice Address - State:IN
Practice Address - Zip Code:46511
Practice Address - Country:US
Practice Address - Phone:574-842-4420
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02000694A207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
INC25317Medicare UPIN
IN512700BMedicare ID - Type Unspecified