Provider Demographics
NPI:1659601946
Name:BERARDELLI, DAVID
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:
Last Name:BERARDELLI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16607 BLANCO ROAD
Mailing Address - Street 2:SUITE 303
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78232-1940
Mailing Address - Country:US
Mailing Address - Phone:361-230-0466
Mailing Address - Fax:210-493-9504
Practice Address - Street 1:16607 BLANCO ROAD
Practice Address - Street 2:SUITE 303
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78232-1940
Practice Address - Country:US
Practice Address - Phone:361-230-0466
Practice Address - Fax:210-493-9504
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-08
Last Update Date:2010-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX209-109821744P3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX209-10982OtherTEXAS BOARD OF ORTHOTISTS AND PROSTHECS LICENSE AND CONTROL #
TXC21287OtherBOARD FOR ORTHOTISTS AND PROSTHISTS CERTIFICATION