Provider Demographics
NPI:1659311207
Name:DEBERARDINIS, CHARLES A (DO)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:A
Last Name:DEBERARDINIS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:738 BRYANT ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:STATESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28677-4189
Mailing Address - Country:US
Mailing Address - Phone:704-873-1189
Mailing Address - Fax:
Practice Address - Street 1:738 BRYANT ST
Practice Address - Street 2:SUITE A
Practice Address - City:STATESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28677-4189
Practice Address - Country:US
Practice Address - Phone:704-873-1189
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2021-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN1610207RC0000X
NC2010-00361207RC0000X
NC201000361207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5913902Medicaid
TXF42442Medicare UPIN
NC24032224Medicare PIN