Basic Information
| Provider Information | |||||||||
| NPI: | 1972510493 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BERNARD | ||||||||
| FirstName: | JOHNNY | ||||||||
| MiddleName: | R. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 159 ISLAND ESTATES PKWY | ||||||||
| Address2: | |||||||||
| City: | PALM COAST | ||||||||
| State: | FL | ||||||||
| PostalCode: | 321372206 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9013011942 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 6029 OLD KINGS RD | ||||||||
| Address2: | |||||||||
| City: | PALM COAST | ||||||||
| State: | FL | ||||||||
| PostalCode: | 32137 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9013011942 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/01/2006 | ||||||||
| LastUpdateDate: | 06/13/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/13/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0001X | 35099044 | OH | N | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology | 2085R0001X | ME96366 | FL | Y | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology |
No ID Information.