Healthcare Provider Details

I. General information

NPI: 1710963475
Provider Name (Legal Business Name): ADOLFO RICHARD DESANDRE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/15/2005
Last Update Date: 05/11/2023
Certification Date: 05/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

257 HOSPITAL DRIVE SUITE 200
BOLIVIA NC
28422-8411
US

IV. Provider business mailing address

PO BOX 60447
CHARLOTTE NC
28260-0447
US

V. Phone/Fax

Practice location:
  • Phone: 910-721-4000
  • Fax: 910-721-4001
Mailing address:
  • Phone: 704-384-7840
  • Fax: 704-384-7830

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number20712
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number9801631
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: