Provider Demographics
NPI:1629234612
Name:WARD, DEMETRICE LOUISE (MD)
Entity Type:Individual
Prefix:DR
First Name:DEMETRICE
Middle Name:LOUISE
Last Name:WARD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MRS
Other - First Name:DEMETRICE
Other - Middle Name:LOUISE
Other - Last Name:WARD-PURVIS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:850 S 5TH STREET
Mailing Address - Street 2:
Mailing Address - City:ALLENTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18103-3295
Mailing Address - Country:US
Mailing Address - Phone:610-776-3278
Mailing Address - Fax:
Practice Address - Street 1:850 S 5TH STREET
Practice Address - Street 2:
Practice Address - City:ALLENTOWN
Practice Address - State:PA
Practice Address - Zip Code:18103-3295
Practice Address - Country:US
Practice Address - Phone:610-776-3278
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-30
Last Update Date:2013-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD441275208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA800263Medicare PIN