Healthcare Provider Details

I. General information

NPI: 1376365320
Provider Name (Legal Business Name): DR. JOHN RUSSELL PANDOLFO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/30/2024
Last Update Date: 11/26/2024
Certification Date: 11/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3407 GARRETT RD
DREXEL HILL PA
19026-2336
US

IV. Provider business mailing address

121 STEEPLECHASE DR
MEDIA PA
19063-1954
US

V. Phone/Fax

Practice location:
  • Phone: 610-622-4888
  • Fax:
Mailing address:
  • Phone: 610-585-0393
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberDC012004
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: