Provider Demographics
NPI:1700807906
Name:J. DUSTIN BERNARD, D.O., MEDICAL CORPORATION
Entity Type:Organization
Organization Name:J. DUSTIN BERNARD, D.O., MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JEANNE
Authorized Official - Middle Name:DUSTIN
Authorized Official - Last Name:BERNARD
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:805-546-9911
Mailing Address - Street 1:PO BOX 12338
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93406-2338
Mailing Address - Country:US
Mailing Address - Phone:805-546-9911
Mailing Address - Fax:805-546-9933
Practice Address - Street 1:2074 PARKER ST
Practice Address - Street 2:SUITE 120
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-5052
Practice Address - Country:US
Practice Address - Phone:805-546-9911
Practice Address - Fax:805-546-9933
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-22
Last Update Date:2010-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2414859207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAC2414859OtherSTATE DEPT OF CORPORATIONS NUMBER
CAC2414859OtherSTATE DEPT OF CORPORATIONS NUMBER
DA9947Medicare PIN