Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207QA0505X | Family Doctor - Adult Medicine | R2470 | MO |
NPI | 1003923129 |
---|---|
Provider Name | James W Bernard |
First Address | Caruthersville, MO 63830-0201 |
Second Address | Caruthersville, MO 63830-1890 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 24/08/2006 |
Last Update Date | 13/04/2015 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
200063501 | (05) | MO |
A11379 | (02) | MO |