Basic Information
| Provider Information | |||||||||
| NPI: | 1649233396 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BERNSTEIN | ||||||||
| FirstName: | JAY | ||||||||
| MiddleName: | GARY | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11209 N TATUM BLVD STE 180 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850286060 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6024945155 | ||||||||
| FaxNumber: | 6024945115 | ||||||||
| Practice Location | |||||||||
| Address1: | 11209 N TATUM BLVD STE 180 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850286060 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6024945155 | ||||||||
| FaxNumber: | 6024945115 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/11/2006 | ||||||||
| LastUpdateDate: | 02/17/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/17/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 1936 | AZ | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 277790 | 05 | AZ | MEDICAID |