Provider Demographics
NPI:1104812601
Name:DERDEL, JEROME D (MD)
Entity type:Individual
Prefix:
First Name:JEROME
Middle Name:D
Last Name:DERDEL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:100 N ACADEMY AVE
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17822-4903
Mailing Address - Country:US
Mailing Address - Phone:570-271-6144
Mailing Address - Fax:570-271-6578
Practice Address - Street 1:1800 E PARK AVE
Practice Address - Street 2:
Practice Address - City:STATE COLLEGE
Practice Address - State:PA
Practice Address - Zip Code:16803-6709
Practice Address - Country:US
Practice Address - Phone:814-234-6726
Practice Address - Fax:814-234-1553
Is Sole Proprietor?:No
Enumeration Date:2005-09-21
Last Update Date:2023-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD038685L2085R0001X, 2085R0203X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0203XAllopathic & Osteopathic PhysiciansRadiologyTherapeutic Radiology
No2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
1104812601OtherNPI
PA000881764Medicaid
B41081Medicare UPIN