Provider Demographics
NPI:1215454194
Name:BERMUDEZ, DOMENIC (PA-C)
Entity type:Individual
Prefix:
First Name:DOMENIC
Middle Name:
Last Name:BERMUDEZ
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7921 JESSIES WAY
Mailing Address - Street 2:
Mailing Address - City:HAMILTON
Mailing Address - State:OH
Mailing Address - Zip Code:45011-8077
Mailing Address - Country:US
Mailing Address - Phone:513-844-1111
Mailing Address - Fax:513-844-6334
Practice Address - Street 1:7921 JESSIES WAY
Practice Address - Street 2:
Practice Address - City:HAMILTON
Practice Address - State:OH
Practice Address - Zip Code:45011-8077
Practice Address - Country:US
Practice Address - Phone:513-844-1111
Practice Address - Fax:513-844-6334
Is Sole Proprietor?:No
Enumeration Date:2017-08-23
Last Update Date:2023-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPP-000112838363A00000X
OH50.005193RX363AS0400X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0243891Medicaid
OH0270942Medicaid