1003988403 NPI number — MRS. JONEL M DERSHEM MD

Table of content: MRS. JONEL M DERSHEM MD (NPI 1003988403)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003988403 NPI number — MRS. JONEL M DERSHEM MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DERSHEM
Provider First Name:
JONEL
Provider Middle Name:
M
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MELLOTT
Provider Other First Name:
JONEL
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1003988403
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/22/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 3001
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VOORHEES
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
08043-0598
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
856-782-3300
Provider Business Mailing Address Fax Number:
856-504-8029

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2301 E EVESHAM RD
Provider Second Line Business Practice Location Address:
BLD 800 STE 122
Provider Business Practice Location Address City Name:
VOORHEES
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
08043-4501
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
856-770-9300
Provider Business Practice Location Address Fax Number:
856-770-8238
Provider Enumeration Date:
11/14/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207V00000X , with the licence number:  25MA06170600 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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