Provider Demographics
NPI:1457334047
Name:BRASILE, DEANNA R (DO)
Entity Type:Individual
Prefix:
First Name:DEANNA
Middle Name:R
Last Name:BRASILE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8002 LINCOLN DRIVE WEST
Mailing Address - Street 2:
Mailing Address - City:MARLTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08053-3209
Mailing Address - Country:US
Mailing Address - Phone:856-751-5575
Mailing Address - Fax:856-751-7289
Practice Address - Street 1:8002 LINCOLN DRIVE WEST
Practice Address - Street 2:
Practice Address - City:MARLTON
Practice Address - State:NJ
Practice Address - Zip Code:08053-3209
Practice Address - Country:US
Practice Address - Phone:856-751-5575
Practice Address - Fax:856-751-7289
Is Sole Proprietor?:No
Enumeration Date:2005-11-28
Last Update Date:2012-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB07415400207V00000X, 207VE0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No207VE0102XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyReproductive Endocrinology
Provider Identifiers
StateIdentifier IDID TypeIssuer
I17756Medicare UPIN