Provider Demographics
NPI:1538149463
Name:BERNBACH, MARC RICHARD (DPM)
Entity type:Individual
Prefix:DR
First Name:MARC
Middle Name:RICHARD
Last Name:BERNBACH
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:171 GRANDVIEW AVE
Mailing Address - Street 2:SUITE 104
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06708-2517
Mailing Address - Country:US
Mailing Address - Phone:203-753-2048
Mailing Address - Fax:203-753-5891
Practice Address - Street 1:171 GRANDVIEW AVE
Practice Address - Street 2:SUITE 104
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06708-2517
Practice Address - Country:US
Practice Address - Phone:203-753-2048
Practice Address - Fax:203-753-5891
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-18
Last Update Date:2007-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000447213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT409031Medicaid
C01386Medicare PIN
CTT23154Medicare UPIN