Provider Demographics
NPI:1437190154
Name:MOGAVERO THEORET, JEANNINE (MD)
Entity Type:Individual
Prefix:
First Name:JEANNINE
Middle Name:
Last Name:MOGAVERO THEORET
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JEANNINE
Other - Middle Name:
Other - Last Name:MOGAVERO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:424 SEVERNSIDE DR
Mailing Address - Street 2:
Mailing Address - City:SEVERNA PARK
Mailing Address - State:MD
Mailing Address - Zip Code:21146-2200
Mailing Address - Country:US
Mailing Address - Phone:617-901-1316
Mailing Address - Fax:
Practice Address - Street 1:49 OLD SOLOMONS ISLAND RD STE 303
Practice Address - Street 2:
Practice Address - City:ANNAPOLIS
Practice Address - State:MD
Practice Address - Zip Code:21401-3870
Practice Address - Country:US
Practice Address - Phone:410-844-8998
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-10
Last Update Date:2021-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD00627742080P0205X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080P0205XAllopathic & Osteopathic PhysiciansPediatricsPediatric Endocrinology