Provider Demographics
NPI:1144481060
Name:DERHAM, ELIZABETH (MD)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:DERHAM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:
Other - Last Name:BLIDNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:840 WALNUT ST STE 1230
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-5109
Mailing Address - Country:US
Mailing Address - Phone:215-928-3041
Mailing Address - Fax:
Practice Address - Street 1:840 WALNUT ST STE 1230
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107-5109
Practice Address - Country:US
Practice Address - Phone:215-928-3041
Practice Address - Fax:215-928-3225
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-23
Last Update Date:2017-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA09094200207W00000X
PAMD451087207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA364763OtherMEDICARE