Provider Demographics
NPI:1548560501
Name:GOLIA PERNICKA, JENNIFER SUSAN (MD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:SUSAN
Last Name:GOLIA PERNICKA
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 1:1275 YORK AVE.
Mailing Address - Street 2:DEPARTMENT OF RADIOLOGY
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10021
Mailing Address - Country:US
Mailing Address - Phone:212-639-2190
Mailing Address - Fax:212-717-3234
Practice Address - Street 1:1275 YORK AVE.
Practice Address - Street 2:DEPARTMENT OF RADIOLOGY
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10021
Practice Address - Country:US
Practice Address - Phone:212-639-2190
Practice Address - Fax:212-717-3234
Is Sole Proprietor?:No
Enumeration Date:2010-10-25
Last Update Date:2017-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2736512085R0202X
OH57-018557390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program