Provider Demographics
NPI:1356677603
Name:FALLON-DELUCIA, JENNIFER K (MD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:K
Last Name:FALLON-DELUCIA
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 1:28555 STARBRIGHT BLVD STE B
Mailing Address - Street 2:
Mailing Address - City:PERRYSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:43551-5662
Mailing Address - Country:US
Mailing Address - Phone:419-931-3089
Mailing Address - Fax:419-931-3048
Practice Address - Street 1:28555 STARBRIGHT BLVD STE B
Practice Address - Street 2:
Practice Address - City:PERRYSBURG
Practice Address - State:OH
Practice Address - Zip Code:43551-5662
Practice Address - Country:US
Practice Address - Phone:419-931-3030
Practice Address - Fax:419-931-3046
Is Sole Proprietor?:No
Enumeration Date:2009-10-21
Last Update Date:2013-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35070621208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0086604Medicaid