Provider Demographics
NPI:1831174697
Name:LEMKE, BERNARD EDGAR (MD, MA)
Entity type:Individual
Prefix:DR
First Name:BERNARD
Middle Name:EDGAR
Last Name:LEMKE
Suffix:
Gender:M
Credentials:MD, MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:242 HOSPITAL DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:UKIAH
Mailing Address - State:CA
Mailing Address - Zip Code:95482-4556
Mailing Address - Country:US
Mailing Address - Phone:707-468-8944
Mailing Address - Fax:707-468-9685
Practice Address - Street 1:242 HOSPITAL DR
Practice Address - Street 2:SUITE A
Practice Address - City:UKIAH
Practice Address - State:CA
Practice Address - Zip Code:95482-4556
Practice Address - Country:US
Practice Address - Phone:707-468-8944
Practice Address - Fax:707-468-9685
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG38871207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G388710Medicaid
CARHC160592OtherRADIATION PERMIT
CA05D1000823OtherCLIA #
CARHC160592OtherRADIATION PERMIT
CA94-2755401OtherEIN, TIN, TAX ID #
CAA47625Medicare UPIN