Basic Information
| Provider Information | |||||||||
| NPI: | 1780653717 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GARDELLA | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | E. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 60447 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282600447 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043845416 | ||||||||
| FaxNumber: | 7043845992 | ||||||||
| Practice Location | |||||||||
| Address1: | 1500 MATTHEWS TOWNSHIP PKWY | ||||||||
| Address2: | |||||||||
| City: | MATTHEWS | ||||||||
| State: | NC | ||||||||
| PostalCode: | 281054656 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043845416 | ||||||||
| FaxNumber: | 7043845992 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/14/2006 | ||||||||
| LastUpdateDate: | 02/13/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RP1001X | 23278 | NC | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease | 207R00000X | 23278 | NC | N | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 8934525 | 05 | NC | MEDICAID | 414474 | 05 | SC | MEDICAID |