Provider Demographics
NPI:1629097803
Name:GAYNOR KRUPNICK, DARLENE MICHELLE (DO)
Entity Type:Individual
Prefix:
First Name:DARLENE
Middle Name:MICHELLE
Last Name:GAYNOR KRUPNICK
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:DARLENE
Other - Middle Name:MICHELLE
Other - Last Name:GAYNOR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:100 E LANCASTER AVE
Mailing Address - Street 2:STE 361
Mailing Address - City:WYNNEWOOD
Mailing Address - State:PA
Mailing Address - Zip Code:19096-3433
Mailing Address - Country:US
Mailing Address - Phone:484-530-0205
Mailing Address - Fax:484-530-0209
Practice Address - Street 1:100 E LANCASTER AVE STE 361
Practice Address - Street 2:
Practice Address - City:WYNNEWOOD
Practice Address - State:PA
Practice Address - Zip Code:19096-3433
Practice Address - Country:US
Practice Address - Phone:610-649-6420
Practice Address - Fax:610-649-4689
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2019-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS016767208800000X
VA0102201861208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010277990Medicaid
VA010278023Medicaid
VACG8678OtherRR MEDICARE GROUP PIN
DCCG8680OtherRR MEDICARE GROUP PIN
VA010805L19Medicare PIN
VAC06319Medicare PIN
DC020045L26Medicare PIN
H90944Medicare UPIN
VA010278023Medicaid