MEDICARE: ELISHAMA DEMOSTHENES

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	172A00000X	Driver

General Provider Information

NPI Number	:	1124836135
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELISHAMA DEMOSTHENES

Provider Business Mailing Address
First Line	:	2600 TILTON RD # 1089
Second Line	:
City	:	EGG HARBOR TOWNSHIP
State	:	NJ
Zip	:	08234-1831
Country	:	US
Telephone Number	:	609-966-9322
Fax Number	:

Provider Business Practice Location Address
First Line	:	2600 TILTON RD # 1089
Second Line	:
City	:	EGG HARBOR TOWNSHIP
State	:	NJ
Zip	:	08234-1831
Country	:	US
Telephone Number	:	609-966-9322
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/21/2024
Last Update Date	:	01/02/2025

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