Provider Demographics
NPI:1487754289
Name:BERARDI, DAWN (OPTICAIN)
Entity type:Individual
Prefix:
First Name:DAWN
Middle Name:
Last Name:BERARDI
Suffix:
Gender:F
Credentials:OPTICAIN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:406 BUCKEYE RD
Mailing Address - Street 2:
Mailing Address - City:CORE
Mailing Address - State:WV
Mailing Address - Zip Code:26529
Mailing Address - Country:US
Mailing Address - Phone:304-983-6680
Mailing Address - Fax:304-983-6681
Practice Address - Street 1:9601 MALL RD
Practice Address - Street 2:
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26501
Practice Address - Country:US
Practice Address - Phone:304-983-6680
Practice Address - Fax:304-983-6681
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV784567156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810003788Medicaid