Provider Demographics
NPI:1952343097
Name:BERNALES, RICARDO (MD)
Entity Type:Individual
Prefix:
First Name:RICARDO
Middle Name:
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 1:3240 S OAK PARK AVE
Mailing Address - Street 2:
Mailing Address - City:BERWYN
Mailing Address - State:IL
Mailing Address - Zip Code:60402
Mailing Address - Country:US
Mailing Address - Phone:708-795-7760
Mailing Address - Fax:708-788-8141
Practice Address - Street 1:3240 S OAK PARK AVE
Practice Address - Street 2:
Practice Address - City:BERWYN
Practice Address - State:IL
Practice Address - Zip Code:60402
Practice Address - Country:US
Practice Address - Phone:708-795-7760
Practice Address - Fax:708-788-8141
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-12
Last Update Date:2008-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36057501207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL36057501OtherIL LIC
IL388000Medicare ID - Type Unspecified
IL36057501OtherIL LIC