Provider Demographics
NPI: | 1033191176 |
---|---|
Name: | DEBERARDINO, THOMAS M (MD) |
Entity Type: | Individual |
Prefix: | |
First Name: | THOMAS |
Middle Name: | M |
Last Name: | DEBERARDINO |
Suffix: | |
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: | 8300 FLOYD CURL DR FL 3 |
Mailing Address - Street 2: | |
Mailing Address - City: | SAN ANTONIO |
Mailing Address - State: | TX |
Mailing Address - Zip Code: | 78229-3931 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 210-450-9300 |
Mailing Address - Fax: | 210-450-6023 |
Practice Address - Street 1: | 8300 FLOYD CURL DR FL 3 |
Practice Address - Street 2: | |
Practice Address - City: | SAN ANTONIO |
Practice Address - State: | TX |
Practice Address - Zip Code: | 78229-3931 |
Practice Address - Country: | US |
Practice Address - Phone: | 210-450-9300 |
Practice Address - Fax: | 210-450-6023 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2005-11-15 |
Last Update Date: | 2022-01-27 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
TX | Q9597 | 207X00000X, 207XX0005X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 207XX0005X | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Sports Medicine |
No | 207X00000X | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
CT | 1033191176 | Medicaid | |
TX | 1033191176 | Medicaid | |
CT | 1033191176 | Medicaid |