Basic Information
| Provider Information | |||||||||
| NPI: | 1740495506 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHRISTOFORATOS | ||||||||
| FirstName: | DIMITRA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 2000 SPROUL ROAD | ||||||||
| Address2: | SUITE 206 | ||||||||
| City: | BROOMALL | ||||||||
| State: | PA | ||||||||
| PostalCode: | 19008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6102840200 | ||||||||
| FaxNumber: | 6103537932 | ||||||||
| Practice Location | |||||||||
| Address1: | 2000 SPROUL ROAD | ||||||||
| Address2: | SUITE 206 | ||||||||
| City: | BROOMALL | ||||||||
| State: | PA | ||||||||
| PostalCode: | 19008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6102840200 | ||||||||
| FaxNumber: | 6103537932 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/14/2007 | ||||||||
| LastUpdateDate: | 11/10/2014 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0200X | SP008184 | PA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | RN526518L | 01 | PA | RN LICENSE | OTHER | 003706 | 01 | PA | PRESCRIPTION AUTH | OTHER | SP008184 | 01 | PA | CRNP LICENSE | OTHER |