Provider Demographics
NPI:1144292954
Name:PELHAM, JACQUELYN (MD)
Entity type:Individual
Prefix:DR
First Name:JACQUELYN
Middle Name:
Last Name:PELHAM
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 1:900 CATON AVE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21229-5201
Mailing Address - Country:US
Mailing Address - Phone:667-234-2523
Mailing Address - Fax:667-234-3563
Practice Address - Street 1:900 CATON AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21229-5201
Practice Address - Country:US
Practice Address - Phone:667-234-2523
Practice Address - Fax:667-234-3563
Is Sole Proprietor?:No
Enumeration Date:2006-02-06
Last Update Date:2023-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD66999207VM0101X, 207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VM0101XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyMaternal & Fetal Medicine
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC014593W25Medicare ID - Type UnspecifiedTRAILBLAZER
DCI12512Medicare UPIN