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General NPI Number Information
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NPI Number | 1619410842
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Entity Type | Individual
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Provider Name | MARK ANDREW DEMITRACK M.D.
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Gender | Male
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Dates
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Enumeration Date | 11/20/2016
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Last Update Date | 11/20/2016
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Provider Practice Location Address
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Address Line | 3222 PHOENIXVILLE PIKE
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City | MALVERN
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State | PA
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Zip | 19355-9615
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Country | US
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Telephone | 610-640-4202
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Fax | 610-640-4206
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Provider Business Mailing Address
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Address Line | 3222 PHOENIXVILLE PIKE
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City | MALVERN
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State | PA
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Zip | 19355-9615
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Country | US
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Telephone | 610-640-4202
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Fax | 610-640-4206
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number | MD4222248
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License Number State | PA
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