Provider Demographics
NPI:1124103023
Name:DE JOHN, SVETLANA (PA)
Entity type:Individual
Prefix:
First Name:SVETLANA
Middle Name:
Last Name:DE JOHN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 S BROAD ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19145-4615
Mailing Address - Country:US
Mailing Address - Phone:215-605-8096
Mailing Address - Fax:215-424-5365
Practice Address - Street 1:2135 E CHELTEN AVE
Practice Address - Street 2:
Practice Address - City:PHILA
Practice Address - State:PA
Practice Address - Zip Code:19138-2534
Practice Address - Country:US
Practice Address - Phone:215-424-5365
Practice Address - Fax:215-424-5370
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-26
Last Update Date:2016-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOA000517L363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA044560JT9OtherMEDICARE IDENTIFICATION NUMBER
PA044560JT9OtherMEDICARE IDENTIFICATION NUMBER