Provider Demographics
NPI:1528020351
Name:DEARDORFF, DARALYNN (DO)
Entity Type:Individual
Prefix:
First Name:DARALYNN
Middle Name:
Last Name:DEARDORFF
Suffix:
Gender:F
Credentials:DO
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 298730
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76129-0001
Mailing Address - Country:US
Mailing Address - Phone:817-257-7864
Mailing Address - Fax:817-257-7320
Practice Address - Street 1:2825 STADIUM DR
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76109-1377
Practice Address - Country:US
Practice Address - Phone:817-257-7864
Practice Address - Fax:817-257-7320
Is Sole Proprietor?:No
Enumeration Date:2006-04-05
Last Update Date:2008-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK77152084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX150535602Medicaid
TX8X7761OtherBCBS
TXH59325Medicare UPIN
TX150535602Medicaid