Provider Demographics
NPI:1396836771
Name:WITHERELL, COLLEEN R (MD)
Entity Type:Individual
Prefix:DR
First Name:COLLEEN
Middle Name:R
Last Name:WITHERELL
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:PO BOX 191
Mailing Address - Street 2:PROVIDER ENROLLMENT DEPT
Mailing Address - City:ROCKLAND
Mailing Address - State:DE
Mailing Address - Zip Code:19732-0191
Mailing Address - Country:US
Mailing Address - Phone:302-651-6212
Mailing Address - Fax:302-651-4945
Practice Address - Street 1:NEMOURS PEDIATRICS JESSUP ST.
Practice Address - Street 2:1602 JESSUP STREET
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19802-4210
Practice Address - Country:US
Practice Address - Phone:302-576-5050
Practice Address - Fax:302-576-5065
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2011-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC10006211208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY2259901Medicaid
MD6883036Medicaid
PA001860698Medicaid
NJ8631506Medicaid
008204T34Medicare PIN
PA001860698Medicaid