Provider Demographics
NPI:1982647400
Name:IDDENDEN, DAVID A (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:A
Last Name:IDDENDEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2301 S BROAD ST
Mailing Address - Street 2:SUITE 102
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19148-3542
Mailing Address - Country:US
Mailing Address - Phone:215-952-5175
Mailing Address - Fax:215-463-2540
Practice Address - Street 1:2301 S BROAD ST
Practice Address - Street 2:SUITE 102
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19148-3542
Practice Address - Country:US
Practice Address - Phone:215-952-5175
Practice Address - Fax:215-463-2540
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2015-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD038624L174400000X
PAMD038624-L207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA000805978 0001Medicaid
PA000805978 0001Medicaid
B37546Medicare UPIN