Healthcare Provider Details

I. General information

NPI: 1134394877
Provider Name (Legal Business Name): GERALDINE JUMOGOLIMA IDONIBOYE M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JUMOGOLIMA IDONIBOYE M.D.

II. Dates (important events)

Enumeration Date: 04/24/2008
Last Update Date: 11/10/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

283 BUTLER RD
MOUNT GRETNA PA
17064-6085
US

IV. Provider business mailing address

283 BUTLER RD
MOUNT GRETNA PA
17064-6085
US

V. Phone/Fax

Practice location:
  • Phone: 717-273-8871
  • Fax:
Mailing address:
  • Phone: 717-273-8871
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberMD438534
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberMD438534
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: