MEDICARE: DR. THERESA MARIA DISANDRO DO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RG0100X	Gastroenterology Physician	OT010580	PA
2	207RG0100X	Gastroenterology Physician	25MB08554700	NJ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1750544391
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. THERESA MARIA DISANDRO DO

Provider Business Mailing Address
First Line	:	301 LIPPINCOTT DR STE 410
Second Line	:
City	:	MARLTON
State	:	NJ
Zip	:	08053-4197
Country	:	US
Telephone Number	:	856-355-0340
Fax Number	:	856-355-0330

Provider Business Practice Location Address
First Line	:	1945 MARLTON PIKE E STE D
Second Line	:
City	:	CHERRY HILL
State	:	NJ
Zip	:	08003-2160
Country	:	US
Telephone Number	:	856-237-8045
Fax Number	:	856-237-8047

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/03/2008
Last Update Date	:	10/07/2024

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