Provider Demographics
NPI:1043219892
Name:NETTLETON, JAMES WARNER (MD PHD)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:WARNER
Last Name:NETTLETON
Suffix:
Gender:M
Credentials:MD PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:123 S BROAD ST
Mailing Address - Street 2:22 FLOOR
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19109-1029
Mailing Address - Country:US
Mailing Address - Phone:215-546-0300
Mailing Address - Fax:215-790-4989
Practice Address - Street 1:123 S BROAD ST
Practice Address - Street 2:22 FLOOR
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19109-1029
Practice Address - Country:US
Practice Address - Phone:215-546-0300
Practice Address - Fax:215-790-4989
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD024965E103TM1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA01676580Medicaid
PANE728925Medicare ID - Type Unspecified
PA01676580Medicaid