Provider Demographics
NPI:1265480123
Name:GOPLERUD, JAN MARIE (MD)
Entity Type:Individual
Prefix:
First Name:JAN
Middle Name:MARIE
Last Name:GOPLERUD
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 1:109 GRACE ST
Mailing Address - Street 2:
Mailing Address - City:MONT CLARE
Mailing Address - State:PA
Mailing Address - Zip Code:19453-5071
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:ERIE AVE AT FRONT ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19134
Practice Address - Country:US
Practice Address - Phone:215-427-5202
Practice Address - Fax:215-427-8192
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD 028755E2080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0010139700007Medicaid
PA0010139700007Medicaid
170758Medicare ID - Type Unspecified