Provider Demographics
NPI:1114979333
Name:DESJARDINS, GEORGE P
Entity Type:Individual
Prefix:
First Name:GEORGE
Middle Name:P
Last Name:DESJARDINS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1211 ELM ST
Mailing Address - Street 2:
Mailing Address - City:READING
Mailing Address - State:PA
Mailing Address - Zip Code:19604-2927
Mailing Address - Country:US
Mailing Address - Phone:610-371-7700
Mailing Address - Fax:610-371-9189
Practice Address - Street 1:215 N 12TH ST
Practice Address - Street 2:
Practice Address - City:READING
Practice Address - State:PA
Practice Address - Zip Code:19604-2915
Practice Address - Country:US
Practice Address - Phone:610-371-7700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD016520E207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0977490Medicaid
E65984Medicare UPIN
PA0977490Medicaid