Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207X00000X | Orthopaedic Surgeon | Q9597 | TX |
Y | 207XX0005X | Sports Medicine Orthopaedic Surgeon | Q9597 | TX |
NPI | 1033191176 |
---|---|
Provider Name | Thomas M Deberardino |
First Address | San Antonio, TX 78229-3931 |
Second Address | San Antonio, TX 78229-3931 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 15/11/2005 |
Last Update Date | 27/01/2022 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1033191176 | (05) | CT |
1033191176 | (05) | TX |