Provider Demographics
NPI:1770566655
Name:WITHERSPOON, NICOLE L (DO)
Entity type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:L
Last Name:WITHERSPOON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
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Mailing Address - Street 1:1412 FAIRMOUNT AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19130-2908
Mailing Address - Country:US
Mailing Address - Phone:215-599-4851
Mailing Address - Fax:215-232-4093
Practice Address - Street 1:1401 DEKALB ST
Practice Address - Street 2:
Practice Address - City:NORRISTOWN
Practice Address - State:PA
Practice Address - Zip Code:19401-3405
Practice Address - Country:US
Practice Address - Phone:610-278-7787
Practice Address - Fax:610-278-7386
Is Sole Proprietor?:No
Enumeration Date:2005-11-23
Last Update Date:2011-06-07
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
PAOS010119L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0017852700001Medicaid
PAG 98088Medicare UPIN
PA0017852700001Medicaid