Healthcare Provider Details

I. General information

NPI: 1265536353
Provider Name (Legal Business Name): THOMAS J DESPERITO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/11/2006
Last Update Date: 07/16/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2000 FOULK ROAD SUITE F
WILMINGTON DE
19810
US

IV. Provider business mailing address

2000 FOULK ROAD SUITE F
WILMINGTON DE
19810
US

V. Phone/Fax

Practice location:
  • Phone: 302-652-8990
  • Fax: 302-652-8646
Mailing address:
  • Phone: 302-652-8990
  • Fax: 302-652-8646

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License NumberC10006813
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: