Provider Demographics
NPI:1427076199
Name:DJERASSI, ADY L
Entity type:Individual
Prefix:DR
First Name:ADY
Middle Name:L
Last Name:DJERASSI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:933 E HAVERFORD RD
Mailing Address - Street 2:
Mailing Address - City:BRYN MAWR
Mailing Address - State:PA
Mailing Address - Zip Code:19010-3819
Mailing Address - Country:US
Mailing Address - Phone:610-527-3800
Mailing Address - Fax:610-527-0334
Practice Address - Street 1:3401 N BROAD ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19140-5103
Practice Address - Country:US
Practice Address - Phone:215-707-4600
Practice Address - Fax:215-707-5599
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2022-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD046152L207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA042111Medicare ID - Type UnspecifiedPROV#