Provider Demographics
NPI:1154348100
Name:BERNDT, THEODORE B (MD)
Entity type:Individual
Prefix:DR
First Name:THEODORE
Middle Name:B
Last Name:BERNDT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:850 HARVARD WAY
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89502-2055
Mailing Address - Country:US
Mailing Address - Phone:775-982-5262
Mailing Address - Fax:775-982-5496
Practice Address - Street 1:1155 MILL ST
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89502-1576
Practice Address - Country:US
Practice Address - Phone:775-982-7878
Practice Address - Fax:775-982-4196
Is Sole Proprietor?:No
Enumeration Date:2006-07-16
Last Update Date:2017-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG22670207RC0000X
NV3191207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVCC2328OtherBLUE CROSS BLUE SHIELD
11050642OtherCAQH
CAXPY183369Medicaid
NV002016077Medicaid
NV002016077Medicaid
NVDG899AMedicare PIN
NV110073355Medicare PIN
NVCC2328OtherBLUE CROSS BLUE SHIELD