Provider Demographics
NPI:1326200544
Name:DER, SUJATHA
Entity Type:Individual
Prefix:
First Name:SUJATHA
Middle Name:
Last Name:DER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 SPRUCE STREET
Mailing Address - Street 2:PINE BASEMENT WEST
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-6130
Mailing Address - Country:US
Mailing Address - Phone:215-829-3264
Mailing Address - Fax:215-829-8044
Practice Address - Street 1:700 SPRUCE STREET
Practice Address - Street 2:PINE BASEMENT WEST
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107-6130
Practice Address - Country:US
Practice Address - Phone:215-829-3264
Practice Address - Fax:215-829-8044
Is Sole Proprietor?:No
Enumeration Date:2008-06-29
Last Update Date:2020-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD435745207P00000X
NY304203-01207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine