Healthcare Provider Details

I. General information

NPI: 1376569715
Provider Name (Legal Business Name): DEBORAH NILES MD FAAFP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2006
Last Update Date: 01/11/2023
Certification Date: 01/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1575 N 52ND ST STE S-3
PHILADELPHIA PA
19131-4736
US

IV. Provider business mailing address

1575 N 52ND ST STE S-3
PHILADELPHIA PA
19131-4736
US

V. Phone/Fax

Practice location:
  • Phone: 267-930-4858
  • Fax: 267-299-6270
Mailing address:
  • Phone: 267-930-4858
  • Fax: 267-299-6270

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number25MA06826500
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD070917L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: