Provider Demographics
NPI:1235212614
Name:TRAVERSO, JOHN R (DO)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:R
Last Name:TRAVERSO
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:8 MORTON AVE
Mailing Address - Street 2:SUITE 303
Mailing Address - City:RIDLEY PARK
Mailing Address - State:PA
Mailing Address - Zip Code:19078-2210
Mailing Address - Country:US
Mailing Address - Phone:610-595-6850
Mailing Address - Fax:610-595-6892
Practice Address - Street 1:8 MORTON AVE
Practice Address - Street 2:
Practice Address - City:RIDLEY PARK
Practice Address - State:PA
Practice Address - Zip Code:19078-2210
Practice Address - Country:US
Practice Address - Phone:610-595-6850
Practice Address - Fax:610-595-6892
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2012-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS010381L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001876061Medicare ID - Type Unspecified
PA045352Medicare ID - Type Unspecified
PAH31351Medicare UPIN