Provider Demographics
NPI:1073510863
Name:HUDERLY, DEBERA L (MD)
Entity Type:Individual
Prefix:
First Name:DEBERA
Middle Name:L
Last Name:HUDERLY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:262 LEROY GEORGE DR
Mailing Address - Street 2:STE X
Mailing Address - City:CLYDE
Mailing Address - State:NC
Mailing Address - Zip Code:28721-7430
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:828-452-8338
Practice Address - Street 1:262 LEROY GEORGE DR
Practice Address - Street 2:STE X
Practice Address - City:CLYDE
Practice Address - State:NC
Practice Address - Zip Code:28721-7430
Practice Address - Country:US
Practice Address - Phone:828-452-8346
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9700988174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8910750Medicaid
NCBH5481231OtherDEA
NCBH5481231OtherDEA
NCF59947Medicare UPIN