Provider Demographics
NPI:1285635284
Name:FODERARO, ANTHONY E (MD)
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:E
Last Name:FODERARO
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 1:711 LAWN AVE
Mailing Address - Street 2:BLDG 1
Mailing Address - City:SELLERSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:18960-1575
Mailing Address - Country:US
Mailing Address - Phone:215-257-5578
Mailing Address - Fax:215-257-1350
Practice Address - Street 1:711 LAWN AVE
Practice Address - Street 2:BLDG 1
Practice Address - City:SELLERSVILLE
Practice Address - State:PA
Practice Address - Zip Code:18960-1575
Practice Address - Country:US
Practice Address - Phone:215-257-5578
Practice Address - Fax:215-257-1350
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD038418E2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1133217Medicaid
PA505538Medicare ID - Type Unspecified
PAA02367Medicare UPIN