Basic Information
Provider Information | |||||||||
NPI: | 1568690980 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MILLER | ||||||||
FirstName: | JENNIFER | ||||||||
MiddleName: | C | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | GUTWALD | ||||||||
OtherFirstName: | JENNIFER | ||||||||
OtherMiddleName: | CLAIRE | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | MD | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 200 HYGEIA DRIVE | ||||||||
Address2: | SUITE 2300 | ||||||||
City: | NEWARK | ||||||||
State: | DE | ||||||||
PostalCode: | 197132049 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4103282766 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 4755 OGLETOWN-STANTON ROAD | ||||||||
Address2: |   | ||||||||
City: | NEWARK | ||||||||
State: | DE | ||||||||
PostalCode: | 197182200 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3027335631 | ||||||||
FaxNumber: | 3027336081 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/24/2009 | ||||||||
LastUpdateDate: | 05/31/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | P24037 | MD | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 2084N0400X | C1-0011322 | DE | N |   | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2084A2900X | C1-0011322 | DE | Y |   |   |   |   |
No ID Information.