Provider Demographics
NPI:1043228802
Name:WERTHEIMER, IRA S (DO)
Entity Type:Individual
Prefix:
First Name:IRA
Middle Name:S
Last Name:WERTHEIMER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 N 20TH ST
Mailing Address - Street 2:CHCA SUITE 301
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19103-1443
Mailing Address - Country:US
Mailing Address - Phone:215-567-2422
Mailing Address - Fax:215-561-0959
Practice Address - Street 1:1 EAST NEW YORK AVE
Practice Address - Street 2:SHORE MEMORIAL HOSPITAL - CHOP CONNECTION
Practice Address - City:SOMERS POINT
Practice Address - State:NJ
Practice Address - Zip Code:08244
Practice Address - Country:US
Practice Address - Phone:609-926-4258
Practice Address - Fax:215-561-0959
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS002877L208000000X
NJ25MB02607700208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
G68319Medicare UPIN
NJ031205Medicare ID - Type Unspecified