Provider Demographics
NPI:1811984206
Name:WITHERELL, JOHN C (MD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:C
Last Name:WITHERELL
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:30 MEDICAL CENTER BLVD STE 104
Mailing Address - Street 2:
Mailing Address - City:CHESTER
Mailing Address - State:PA
Mailing Address - Zip Code:19013-3955
Mailing Address - Country:US
Mailing Address - Phone:610-874-5261
Mailing Address - Fax:610-874-0318
Practice Address - Street 1:30 MEDICAL CENTER BLVD STE 104
Practice Address - Street 2:
Practice Address - City:CHESTER
Practice Address - State:PA
Practice Address - Zip Code:19013-3955
Practice Address - Country:US
Practice Address - Phone:610-874-5261
Practice Address - Fax:610-874-0318
Is Sole Proprietor?:No
Enumeration Date:2005-09-30
Last Update Date:2020-11-01
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
PAMD060067L207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0117305590Medicaid
PA0117305590Medicaid
PA0075320001Medicare NSC
PAG65204Medicare UPIN