Healthcare Provider Details

I. General information

NPI: 1265490841
Provider Name (Legal Business Name): JOSE ANTONIO BARDELAS JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/03/2006
Last Update Date: 08/10/2021
Certification Date: 08/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 WESTWOOD AVENUE
HIGH POINT NC
27262-4320
US

IV. Provider business mailing address

100 WESTWOOD AVENUE
HIGH POINT NC
27262-4320
US

V. Phone/Fax

Practice location:
  • Phone: 336-883-1393
  • Fax: 336-883-7517
Mailing address:
  • Phone: 336-883-1393
  • Fax: 336-883-7517

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number21622
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number21622
License Number StateNC

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier0200001
Identifier TypeOTHER
Identifier State
Identifier IssuerUNITED HEALTHCARE
# 2
Identifier8913057
Identifier TypeMEDICAID
Identifier StateNC
Identifier Issuer
# 3
Identifier13057
Identifier TypeOTHER
Identifier StateNC
Identifier IssuerBCBS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: