Basic Information
| Provider Information | |||||||||
| NPI: | 1760823769 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DEROSATO | ||||||||
| FirstName: | LEIA | ||||||||
| MiddleName: | WOELKERS | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2100 MACK BLVD FL 4 | ||||||||
| Address2: | |||||||||
| City: | ALLENTOWN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 181035622 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4848844500 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1200 S CEDAR CREST BLVD | ||||||||
| Address2: | |||||||||
| City: | ALLENTOWN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 181036202 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6104027632 | ||||||||
| FaxNumber: | 6104027600 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/08/2013 | ||||||||
| LastUpdateDate: | 07/10/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | OT015441 | PA | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | OS018108 | PA | Y | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.