Healthcare Provider Details

I. General information

NPI: 1770803330
Provider Name (Legal Business Name): MARK J DECARO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2010
Last Update Date: 12/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

925 CHESTNUT ST
PHILADELPHIA PA
19107-4216
US

IV. Provider business mailing address

833 CHESTNUT STREET SUITE 701
PHILADELPHIA PA
19107-4409
US

V. Phone/Fax

Practice location:
  • Phone: 215-955-5050
  • Fax: 215-955-7499
Mailing address:
  • Phone: 215-955-6180
  • Fax: 215-955-6410

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD449736
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMT197358
License Number StatePA
# 3
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberMD449736
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: