Provider Demographics
NPI:1942439443
Name:ARDELJAN, ADRIANA SOFIA (DO)
Entity Type:Individual
Prefix:
First Name:ADRIANA
Middle Name:SOFIA
Last Name:ARDELJAN
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 1:540 W 15TH ST
Mailing Address - Street 2:
Mailing Address - City:HEREFORD
Mailing Address - State:TX
Mailing Address - Zip Code:79045-2820
Mailing Address - Country:US
Mailing Address - Phone:806-364-2141
Mailing Address - Fax:806-349-9387
Practice Address - Street 1:540 W 15TH ST
Practice Address - Street 2:
Practice Address - City:HEREFORD
Practice Address - State:TX
Practice Address - Zip Code:79045-2820
Practice Address - Country:US
Practice Address - Phone:806-364-2141
Practice Address - Fax:806-349-9387
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-07
Last Update Date:2014-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101018363208600000X
TXP9796208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1942439443Medicaid