Provider Demographics
NPI:1750545661
Name:ILUSTRE, JOANNE MARIE (DO)
Entity type:Individual
Prefix:DR
First Name:JOANNE
Middle Name:MARIE
Last Name:ILUSTRE
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 1:3521 SILVERSIDE RD
Mailing Address - Street 2:STE 1C
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19810-4900
Mailing Address - Country:US
Mailing Address - Phone:267-479-4142
Mailing Address - Fax:215-463-3820
Practice Address - Street 1:1 BARTOL AVE STE 10
Practice Address - Street 2:
Practice Address - City:RIDLEY PARK
Practice Address - State:PA
Practice Address - Zip Code:19078-2214
Practice Address - Country:US
Practice Address - Phone:610-521-0150
Practice Address - Fax:610-521-6493
Is Sole Proprietor?:No
Enumeration Date:2008-07-10
Last Update Date:2021-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC20011444207RC0000X
PAOS015002207RC0000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1035757110003Medicaid