Provider Demographics
NPI:1346452836
Name:SOPPAS, DESPINA (MD)
Entity Type:Individual
Prefix:
First Name:DESPINA
Middle Name:
Last Name:SOPPAS
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 1:5030 STATE ROAD
Mailing Address - Street 2:
Mailing Address - City:DREXEL HILL
Mailing Address - State:PA
Mailing Address - Zip Code:19026
Mailing Address - Country:US
Mailing Address - Phone:610-623-9080
Mailing Address - Fax:610-623-3861
Practice Address - Street 1:5030 STATE ROAD
Practice Address - Street 2:SUITE 2-900
Practice Address - City:DREXEL HILL
Practice Address - State:PA
Practice Address - Zip Code:19026
Practice Address - Country:US
Practice Address - Phone:610-623-9080
Practice Address - Fax:610-623-3861
Is Sole Proprietor?:No
Enumeration Date:2007-05-04
Last Update Date:2011-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD025584E208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0010977100004Medicaid
B34961Medicare UPIN