Provider Demographics
NPI:1265799050
Name:REQUA, LINDSAY ANN (DO)
Entity type:Individual
Prefix:
First Name:LINDSAY
Middle Name:ANN
Last Name:REQUA
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 1:401 ROUTE 73 N BLDG 10
Mailing Address - Street 2:
Mailing Address - City:MARLTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08053-3425
Mailing Address - Country:US
Mailing Address - Phone:856-872-7055
Mailing Address - Fax:
Practice Address - Street 1:318 N HADDON AVE STE A
Practice Address - Street 2:
Practice Address - City:HADDONFIELD
Practice Address - State:NJ
Practice Address - Zip Code:08033-1702
Practice Address - Country:US
Practice Address - Phone:856-428-3746
Practice Address - Fax:856-310-0312
Is Sole Proprietor?:No
Enumeration Date:2012-04-18
Last Update Date:2024-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS017561208000000X
NJ25MB09948500208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA440873FLTMedicare PIN