Provider Demographics
NPI:1861547150
Name:DEBAKKER, CAROL J (MD)
Entity type:Individual
Prefix:DR
First Name:CAROL
Middle Name:J
Last Name:DEBAKKER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 457
Mailing Address - Street 2:
Mailing Address - City:WYNNEWOOD
Mailing Address - State:PA
Mailing Address - Zip Code:19096-0457
Mailing Address - Country:US
Mailing Address - Phone:484-476-3391
Mailing Address - Fax:866-848-9001
Practice Address - Street 1:100 E LANCASTER AVE STE B7
Practice Address - Street 2:
Practice Address - City:WYNNEWOOD
Practice Address - State:PA
Practice Address - Zip Code:19096-3450
Practice Address - Country:US
Practice Address - Phone:484-476-3391
Practice Address - Fax:866-848-9001
Is Sole Proprietor?:No
Enumeration Date:2007-01-24
Last Update Date:2021-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD038548E208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0517076000OtherKEYSTONE HEALTH PLAN EAST
PA0012504290002Medicaid
PA5309920004OtherCIGNA
PA682747OtherBLUE SHIELD
PA2512771OtherAETNA
PA948288OtherUNITED HEALTHCARE
PA250012418OtherRR MEDICARE
PA1000695OtherKEYSTONE MERCY HEALTH
PA682747Medicare ID - Type Unspecified
PA250012418OtherRR MEDICARE