Healthcare Provider Details

I. General information

NPI: 1780676353
Provider Name (Legal Business Name): JENNIFER CANCINO MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/18/2005
Last Update Date: 04/30/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7211 BANK CT
FREDERICK MD
21703-8483
US

IV. Provider business mailing address

PO BOX 1110
UNION BRIDGE MD
21791-0579
US

V. Phone/Fax

Practice location:
  • Phone: 240-215-6370
  • Fax:
Mailing address:
  • Phone: 410-775-2622
  • Fax: 410-775-2050

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberD0058038
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: