Provider Demographics
NPI:1164742029
Name:DESPOSITO, LIA (DO,)
Entity Type:Individual
Prefix:DR
First Name:LIA
Middle Name:
Last Name:DESPOSITO
Suffix:
Gender:F
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 E LANCASTER AVE
Mailing Address - Street 2:4 PAVILION, SUITE 4303
Mailing Address - City:WYNNEWOOD
Mailing Address - State:PA
Mailing Address - Zip Code:19096-3450
Mailing Address - Country:US
Mailing Address - Phone:484-476-6421
Mailing Address - Fax:484-476-3149
Practice Address - Street 1:100 E LANCASTER AVE
Practice Address - Street 2:4 PAVILION, SUITE 4303
Practice Address - City:WYNNEWOOD
Practice Address - State:PA
Practice Address - Zip Code:19096-3450
Practice Address - Country:US
Practice Address - Phone:484-476-6421
Practice Address - Fax:484-476-3149
Is Sole Proprietor?:No
Enumeration Date:2010-06-02
Last Update Date:2017-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS016501207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA232359401OtherMAIN LINE HEALTHCARE TAX ID