Provider Demographics
NPI:1629165469
Name:BERARDELLI, EVA A (MD)
Entity Type:Individual
Prefix:
First Name:EVA
Middle Name:A
Last Name:BERARDELLI
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:PO BOX 614
Mailing Address - Street 2:
Mailing Address - City:NIWOT
Mailing Address - State:CO
Mailing Address - Zip Code:80544-0614
Mailing Address - Country:US
Mailing Address - Phone:303-709-7792
Mailing Address - Fax:
Practice Address - Street 1:2030 MOUNTAIN VIEW AVE
Practice Address - Street 2:
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80501-3178
Practice Address - Country:US
Practice Address - Phone:303-709-9772
Practice Address - Fax:303-652-0468
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-05
Last Update Date:2012-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO25586225400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
COD24662Medicare UPIN
COC9081Medicare PIN