Provider Demographics
NPI:1780104943
Name:BERNALES, ANDREW B (MD)
Entity type:Individual
Prefix:
First Name:ANDREW
Middle Name:B
Last Name:BERNALES
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:PO BOX 19658
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62794-9658
Mailing Address - Country:US
Mailing Address - Phone:217-545-8000
Mailing Address - Fax:217-545-4779
Practice Address - Street 1:402 N VAUGHAN DR
Practice Address - Street 2:
Practice Address - City:BRUSLY
Practice Address - State:LA
Practice Address - Zip Code:70719-2225
Practice Address - Country:US
Practice Address - Phone:225-448-5321
Practice Address - Fax:225-448-5321
Is Sole Proprietor?:No
Enumeration Date:2017-06-20
Last Update Date:2022-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA324080208000000X
IL125069861208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2542605Medicaid