Basic Information
| Provider Information | |||||||||
| NPI: | 1912924515 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BERNHARD | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | H | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 961205 | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761611205 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8177408400 | ||||||||
| FaxNumber: | 8173783699 | ||||||||
| Practice Location | |||||||||
| Address1: | 5612 EDWARDS RANCH RD | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761094145 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8172637200 | ||||||||
| FaxNumber: | 8172637206 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2006 | ||||||||
| LastUpdateDate: | 11/03/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/03/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | H0178 | TX | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 010066236 | 01 | RAILROAD MEDICARE | OTHER | 122533605 | 05 | TX | MEDICAID |