Provider Demographics
NPI:1902807407
Name:WEINRAUB, JENNIFER (MD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:
Last Name:WEINRAUB
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 1:121 CAYUGA PARK RD
Mailing Address - Street 2:
Mailing Address - City:ITHACA
Mailing Address - State:NY
Mailing Address - Zip Code:14850-1405
Mailing Address - Country:US
Mailing Address - Phone:607-592-6603
Mailing Address - Fax:
Practice Address - Street 1:318 S ALBANY ST
Practice Address - Street 2:BEECHTREE CARE CENTER
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850-5406
Practice Address - Country:US
Practice Address - Phone:607-273-4166
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-09
Last Update Date:2012-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY170781207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01831149Medicaid
NYE73237Medicare UPIN
NY01831149Medicaid