Basic Information
| Provider Information | |||||||||
| NPI: | 1861167694 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | JOHNNY BERNARD JR MD LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 162879 | ||||||||
| Address2: | |||||||||
| City: | ALTAMONTE SPRINGS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327162879 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4077881906 | ||||||||
| FaxNumber: | 3212802479 | ||||||||
| Practice Location | |||||||||
| Address1: | 6029 OLD KINGS ROAD | ||||||||
| Address2: | |||||||||
| City: | PALM COAST | ||||||||
| State: | FL | ||||||||
| PostalCode: | 32137 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9013011942 | ||||||||
| FaxNumber: | 3862835170 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/13/2021 | ||||||||
| LastUpdateDate: | 08/13/2021 | ||||||||
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| AuthorizedOfficialLastName: | BERNARD | ||||||||
| AuthorizedOfficialFirstName: | JOHNNY | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9013011942 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 07/19/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0001X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology |
No ID Information.