Provider Demographics
NPI:1528070752
Name:BERNSTEN, BROCK DARYL (MD)
Entity type:Individual
Prefix:DR
First Name:BROCK
Middle Name:DARYL
Last Name:BERNSTEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 748636
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90074-1522
Mailing Address - Country:US
Mailing Address - Phone:877-202-3597
Mailing Address - Fax:360-729-1774
Practice Address - Street 1:3377 RIVERBEND DR
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OR
Practice Address - Zip Code:97477-8803
Practice Address - Country:US
Practice Address - Phone:541-222-8500
Practice Address - Fax:541-222-6435
Is Sole Proprietor?:No
Enumeration Date:2006-08-13
Last Update Date:2021-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC371642080A0000X
ORMD190026208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA36514Medicare UPIN