Healthcare Provider Details

I. General information

NPI: 1811152663
Provider Name (Legal Business Name): JENNIFER VODZAK M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/22/2008
Last Update Date: 08/30/2020
Certification Date: 08/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 NORTH ACADEMY AVE.
DANVILLE PA
17822-1339
US

IV. Provider business mailing address

100 N ACADEMY AVE
DANVILLE PA
17822-4903
US

V. Phone/Fax

Practice location:
  • Phone: 570-271-6440
  • Fax:
Mailing address:
  • Phone: 570-271-6144
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080P0208X
TaxonomyPediatric Infectious Diseases Physician
License Number0439149
License Number StateKS
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMT189518
License Number StatePA
# 3
Primary TaxonomyY
Taxonomy Code2080P0208X
TaxonomyPediatric Infectious Diseases Physician
License NumberMD438505
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: