Provider Demographics
NPI:1548513625
Name:FORD, BERNADETTE
Entity type:Individual
Prefix:MRS
First Name:BERNADETTE
Middle Name:
Last Name:FORD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1450 POINT BREEZE AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19146-4522
Mailing Address - Country:US
Mailing Address - Phone:215-833-1417
Mailing Address - Fax:215-463-4762
Practice Address - Street 1:715 S ITHAN ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19143-2809
Practice Address - Country:US
Practice Address - Phone:215-833-1417
Practice Address - Fax:215-463-4762
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-26
Last Update Date:2012-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician