Provider Demographics
NPI:1295817690
Name:ZDERIC, STEPHEN A (MD)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:A
Last Name:ZDERIC
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 1:100 EAST PENN SQUARE
Mailing Address - Street 2:THE WANAMAKER BUILDING 9TH FL
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-4332
Mailing Address - Country:US
Mailing Address - Phone:267-425-9538
Mailing Address - Fax:267-425-9552
Practice Address - Street 1:34TH & CIVIC CENTER BLVD
Practice Address - Street 2:CHILDREN'S HOSPITAL OF PHILADELPHIA
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104
Practice Address - Country:US
Practice Address - Phone:215-590-2754
Practice Address - Fax:215-590-3985
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2013-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD033448E208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001261530Medicaid
PA717243J5HMedicare ID - Type Unspecified
PA001261530Medicaid