Provider Demographics
NPI:1720029440
Name:BERNARDINO, VITALIANO B JR (MD)
Entity type:Individual
Prefix:
First Name:VITALIANO
Middle Name:B
Last Name:BERNARDINO
Suffix:JR
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:PO BOX 397
Mailing Address - Street 2:
Mailing Address - City:LANGHORNE
Mailing Address - State:PA
Mailing Address - Zip Code:19047-0397
Mailing Address - Country:US
Mailing Address - Phone:215-752-7194
Mailing Address - Fax:215-752-7841
Practice Address - Street 1:1205 LANGHORNE NEWTOWN RD
Practice Address - Street 2:SUITE 215
Practice Address - City:LANGHORNE
Practice Address - State:PA
Practice Address - Zip Code:19047-1219
Practice Address - Country:US
Practice Address - Phone:215-752-7194
Practice Address - Fax:215-752-7841
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD035090L174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA01607671Medicaid
PA01607671Medicaid
PAB36445Medicare UPIN