Provider Demographics
NPI:1548289671
Name:MONDERER, BERNARD (MD)
Entity type:Individual
Prefix:DR
First Name:BERNARD
Middle Name:
Last Name:MONDERER
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 1:15211 VANOWEN ST
Mailing Address - Street 2:SUITE 210
Mailing Address - City:VAN NUYS
Mailing Address - State:CA
Mailing Address - Zip Code:91405-3606
Mailing Address - Country:US
Mailing Address - Phone:818-786-0710
Mailing Address - Fax:818-786-0712
Practice Address - Street 1:15211 VANOWEN ST
Practice Address - Street 2:SUITE 210
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91405-3606
Practice Address - Country:US
Practice Address - Phone:818-786-0710
Practice Address - Fax:818-786-0712
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2008-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG34153207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G341530Medicaid
CAA45806Medicare UPIN
CAG34153Medicare ID - Type Unspecified
CA1231510001Medicare NSC