Healthcare Provider Details

I. General information

NPI: 1982647400
Provider Name (Legal Business Name): DAVID A IDDENDEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2006
Last Update Date: 05/12/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2301 S BROAD ST SUITE 102
PHILADELPHIA PA
19148-3542
US

IV. Provider business mailing address

2301 S BROAD ST SUITE 102
PHILADELPHIA PA
19148-3542
US

V. Phone/Fax

Practice location:
  • Phone: 215-952-5175
  • Fax: 215-463-2540
Mailing address:
  • Phone: 215-952-5175
  • Fax: 215-463-2540

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberMD038624L
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberMD038624-L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: