Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207XX0005X | Sports Medicine Orthopaedic Surgeon | MD418718 | PA |
NPI | 1154420206 |
---|---|
Provider Name | Dr. Mark Desmond |
First Address | Philadelphia, PA 19129-1302 |
Second Address | Philadelphia, PA 19140-4105 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 22/09/2006 |
Last Update Date | 21/12/2020 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
H63528 | (02) | PA |