Provider Demographics
NPI:1124013586
Name:CHIDESTER, JOHN H (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:H
Last Name:CHIDESTER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:254 W. LANCASTER AVE
Mailing Address - Street 2:SUITE 2
Mailing Address - City:MALVERN
Mailing Address - State:PA
Mailing Address - Zip Code:19355-3087
Mailing Address - Country:US
Mailing Address - Phone:610-644-5040
Mailing Address - Fax:610-640-9170
Practice Address - Street 1:254 W. LANCASTER AVE
Practice Address - Street 2:SUITE 2
Practice Address - City:MALVERN
Practice Address - State:PA
Practice Address - Zip Code:19355-3087
Practice Address - Country:US
Practice Address - Phone:610-644-5040
Practice Address - Fax:610-640-9170
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-13
Last Update Date:2008-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD-019797-E174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA3646OtherAETNA PROVIDER NUMBER
PA055590OtherPERSONAL CHOICE PROVIDER
PA02598600OtherIDENPENDENCE BLUE CROSS
PA1754466OtherHIGHMARK GROUP ID #
PA3646OtherAETNA PROVIDER NUMBER
PAB-96866Medicare UPIN