Provider Demographics
NPI:1164497947
Name:GENOVA, JACQUELINE K (MD)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:K
Last Name:GENOVA
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 1:1503 LANSDOWNE AVE
Mailing Address - Street 2:STE 3002
Mailing Address - City:DARBY
Mailing Address - State:PA
Mailing Address - Zip Code:19023
Mailing Address - Country:US
Mailing Address - Phone:610-237-4995
Mailing Address - Fax:610-237-7311
Practice Address - Street 1:1503 LANSDOWNE AVE
Practice Address - Street 2:STE 3002 LANSDOWNE PARK PEDIATRICS
Practice Address - City:DARBY
Practice Address - State:PA
Practice Address - Zip Code:19023
Practice Address - Country:US
Practice Address - Phone:610-237-4995
Practice Address - Fax:610-237-7311
Is Sole Proprietor?:No
Enumeration Date:2006-02-23
Last Update Date:2011-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD068318L208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
5611580OtherCIGNA
30008552OtherKMHP
PA1008879940001Medicaid
2258915000OtherIBC
GE1579643OtherHIGHMARK BS
3248072OtherAETNA