Healthcare Provider Details

I. General information

NPI: 1104848936
Provider Name (Legal Business Name): COLETTE DESROCHERS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/24/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 COBBS CREEK PARKWAY
PHILADELPHIA PA
19139-3723
US

IV. Provider business mailing address

225 COBBS CREEK PARKWAY
PHILADELPHIA PA
19139-3723
US

V. Phone/Fax

Practice location:
  • Phone: 215-476-2223
  • Fax: 215-476-3981
Mailing address:
  • Phone: 215-476-2223
  • Fax: 215-476-3981

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD-059051-L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: