Provider Demographics
NPI:1881620409
Name:DURISEK, DEBBIE LORETTA (MD)
Entity type:Individual
Prefix:DR
First Name:DEBBIE
Middle Name:LORETTA
Last Name:DURISEK
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 1:169 MARTIN AVE
Mailing Address - Street 2:
Mailing Address - City:EPHRATA
Mailing Address - State:PA
Mailing Address - Zip Code:17522
Mailing Address - Country:US
Mailing Address - Phone:717-859-4454
Mailing Address - Fax:717-859-4475
Practice Address - Street 1:169 MARTIN AVE
Practice Address - Street 2:
Practice Address - City:EPHRATA
Practice Address - State:PA
Practice Address - Zip Code:17522-1724
Practice Address - Country:US
Practice Address - Phone:717-859-4454
Practice Address - Fax:717-859-4475
Is Sole Proprietor?:No
Enumeration Date:2006-06-24
Last Update Date:2009-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD030348E2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0010501410024Medicaid
PA0010501410024Medicaid
PA193454D2UMedicare PIN
PA300135875Medicare PIN