Provider Demographics
NPI:1861167694
Name:JOHNNY BERNARD JR MD LLC
Entity type:Organization
Organization Name:JOHNNY BERNARD JR MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHNNY
Authorized Official - Middle Name:R
Authorized Official - Last Name:BERNARD
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:901-301-1942
Mailing Address - Street 1:PO BOX 1809
Mailing Address - Street 2:
Mailing Address - City:FLAGLER BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32136-1809
Mailing Address - Country:US
Mailing Address - Phone:407-788-1906
Mailing Address - Fax:321-280-2479
Practice Address - Street 1:6029 OLD KINGS ROAD
Practice Address - Street 2:
Practice Address - City:PALM COAST
Practice Address - State:FL
Practice Address - Zip Code:32137
Practice Address - Country:US
Practice Address - Phone:901-301-1942
Practice Address - Fax:386-283-5170
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-13
Last Update Date:2023-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation OncologyGroup - Single Specialty