Provider Demographics
NPI:1518531086
Name:DERRICOTTE, GWENDOLYN MARGARET (DO)
Entity Type:Individual
Prefix:DR
First Name:GWENDOLYN
Middle Name:MARGARET
Last Name:DERRICOTTE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2830 EASTON AVE
Mailing Address - Street 2:
Mailing Address - City:BETHLEHEM
Mailing Address - State:PA
Mailing Address - Zip Code:18017-4204
Mailing Address - Country:US
Mailing Address - Phone:484-526-3555
Mailing Address - Fax:833-822-5230
Practice Address - Street 1:2830 EASTON AVE
Practice Address - Street 2:
Practice Address - City:BETHLEHEM
Practice Address - State:PA
Practice Address - Zip Code:18017-4204
Practice Address - Country:US
Practice Address - Phone:484-526-3555
Practice Address - Fax:833-822-5230
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-18
Last Update Date:2021-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOT020538207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine