Provider Demographics
NPI:1104860501
Name:DEBARTOLO, MICHAEL (DC)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:
Last Name:DEBARTOLO
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 BOONE SQUARE ST
Mailing Address - Street 2:SUITE 27
Mailing Address - City:HILLSBOROUGH
Mailing Address - State:NC
Mailing Address - Zip Code:27278-2564
Mailing Address - Country:US
Mailing Address - Phone:919-732-6991
Mailing Address - Fax:
Practice Address - Street 1:110 BOONE SQUARE ST
Practice Address - Street 2:SUITE 27
Practice Address - City:HILLSBOROUGH
Practice Address - State:NC
Practice Address - Zip Code:27278-2564
Practice Address - Country:US
Practice Address - Phone:919-732-6991
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-15
Last Update Date:2007-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1190111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC08347OtherBCBS
NC08347OtherBCBS
NC244328Medicare ID - Type Unspecified
NCT-64379Medicare UPIN