Provider Demographics
NPI:1316908031
Name:DIMAGGIO, OLIVIA THERESA (MD)
Entity type:Individual
Prefix:MS
First Name:OLIVIA
Middle Name:THERESA
Last Name:DIMAGGIO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:100 GRANITE DR
Mailing Address - Street 2:STE 200
Mailing Address - City:MEDIA
Mailing Address - State:PA
Mailing Address - Zip Code:19063-5134
Mailing Address - Country:US
Mailing Address - Phone:610-565-1945
Mailing Address - Fax:610-892-7848
Practice Address - Street 1:100 GRANITE DR
Practice Address - Street 2:STE 200
Practice Address - City:MEDIA
Practice Address - State:PA
Practice Address - Zip Code:19063
Practice Address - Country:US
Practice Address - Phone:610-565-1945
Practice Address - Fax:610-892-7848
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD019717E208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0887973Medicaid
PA0887973Medicaid