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General NPI Number Information
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NPI Number | 1316194954
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Entity Type | Individual
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Provider Name | CARL THEODORE OPDERBECK MD
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Gender | Male
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Dates
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Enumeration Date | 08/26/2008
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Last Update Date | 08/26/2008
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Provider Practice Location Address
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Address Line | ROUTE 7 AND ROUTE 12 FORT DEFIANCE INDIAN HOSPITAL
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City | FORT DEFIANCE
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State | AZ
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Zip | 86504-0649
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Country | US
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Telephone | 928-729-8020
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Fax | 828-729-8794
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Provider Business Mailing Address
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Address Line | 364 LOG CABIN LN
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City | UNION MILLS
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State | NC
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Zip | 28167-9004
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Country | US
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Telephone | 828-288-0012
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Fax | 828-288-0012
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207V00000X
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Taxonomy Name | Obstetrics & Gynecology Physician
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License Number | 196220
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License Number State | NY
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