Basic Information
| Provider Information | |||||||||
| NPI: | 1003801887 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BERNARDO | ||||||||
| FirstName: | WILFRIDO | ||||||||
| MiddleName: | D | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 176 | ||||||||
| Address2: | |||||||||
| City: | CARTHAGE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370300176 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6157350700 | ||||||||
| FaxNumber: | 6157355451 | ||||||||
| Practice Location | |||||||||
| Address1: | 130 LEBANON HWY | ||||||||
| Address2: | SUITE B | ||||||||
| City: | CARTHAGE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370302955 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6157350700 | ||||||||
| FaxNumber: | 6157355451 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/16/2005 | ||||||||
| LastUpdateDate: | 03/05/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | 11479 | TN | Y | Allopathic & Osteopathic Physicians | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 3170708 | 05 | TN | MEDICAID |