Provider Demographics
NPI:1003988403
Name:DERSHEM, JONEL M (MD)
Entity Type:Individual
Prefix:MRS
First Name:JONEL
Middle Name:M
Last Name:DERSHEM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JONEL
Other - Middle Name:
Other - Last Name:MELLOTT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 3001
Mailing Address - Street 2:
Mailing Address - City:VOORHEES
Mailing Address - State:NJ
Mailing Address - Zip Code:08043-0598
Mailing Address - Country:US
Mailing Address - Phone:856-782-3300
Mailing Address - Fax:856-504-8029
Practice Address - Street 1:2301 E EVESHAM RD
Practice Address - Street 2:BLD 800 STE 122
Practice Address - City:VOORHEES
Practice Address - State:NJ
Practice Address - Zip Code:08043-4501
Practice Address - Country:US
Practice Address - Phone:856-770-9300
Practice Address - Fax:856-770-8238
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2012-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA06170600207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
G20808Medicare UPIN
NJ806772Medicare ID - Type Unspecified