Provider Demographics
NPI:1316194954
Name:OPDERBECK, CARL THEODORE (MD)
Entity type:Individual
Prefix:
First Name:CARL
Middle Name:THEODORE
Last Name:OPDERBECK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:364 LOG CABIN LN
Mailing Address - Street 2:
Mailing Address - City:UNION MILLS
Mailing Address - State:NC
Mailing Address - Zip Code:28167-9004
Mailing Address - Country:US
Mailing Address - Phone:828-288-0012
Mailing Address - Fax:828-288-0012
Practice Address - Street 1:ROUTE 7 AND ROUTE 12
Practice Address - Street 2:FORT DEFIANCE INDIAN HOSPITAL
Practice Address - City:FORT DEFIANCE
Practice Address - State:AZ
Practice Address - Zip Code:86504-0649
Practice Address - Country:US
Practice Address - Phone:928-729-8020
Practice Address - Fax:828-729-8794
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-26
Last Update Date:2008-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY196220207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology