Provider Demographics
NPI:1528485646
Name:BERMUDO, ISMAEL JR
Entity type:Individual
Prefix:
First Name:ISMAEL
Middle Name:
Last Name:BERMUDO
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3899 CAPE ROYAL ST
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89147-6578
Mailing Address - Country:US
Mailing Address - Phone:323-573-4430
Mailing Address - Fax:
Practice Address - Street 1:3899 CAPE ROYAL ST
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89147-6578
Practice Address - Country:US
Practice Address - Phone:323-573-4430
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-26
Last Update Date:2014-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT21566225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist