Provider Demographics
NPI:1326032087
Name:BACANI, OFELIA A (MD)
Entity Type:Individual
Prefix:
First Name:OFELIA
Middle Name:A
Last Name:BACANI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:350 MACDADE BLVD
Mailing Address - Street 2:
Mailing Address - City:COLLINGDALE
Mailing Address - State:PA
Mailing Address - Zip Code:19023-1924
Mailing Address - Country:US
Mailing Address - Phone:610-586-2599
Mailing Address - Fax:610-586-3010
Practice Address - Street 1:350 MACDADE BLVD
Practice Address - Street 2:
Practice Address - City:COLLINGDALE
Practice Address - State:PA
Practice Address - Zip Code:19023-1924
Practice Address - Country:US
Practice Address - Phone:610-586-2599
Practice Address - Fax:610-586-3010
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-08
Last Update Date:2010-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD036604L207Q00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0767438Medicaid
PA0767438Medicaid
PABA70246Medicare ID - Type Unspecified