Provider Demographics
NPI:1669629689
Name:OXENBERG, JACQUELINE CLARE (DO)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:CLARE
Last Name:OXENBERG
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 N ACADEMY AVE
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17822-4903
Mailing Address - Country:US
Mailing Address - Phone:570-271-6144
Mailing Address - Fax:570-271-6578
Practice Address - Street 1:1000 EAST MOUNTAIN BLVD.
Practice Address - Street 2:
Practice Address - City:WILKES-BARRE
Practice Address - State:PA
Practice Address - Zip Code:18711-3762
Practice Address - Country:US
Practice Address - Phone:570-808-2340
Practice Address - Fax:570-808-7904
Is Sole Proprietor?:No
Enumeration Date:2008-08-20
Last Update Date:2020-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY263687208600000X
PAOS014772208600000X, 2086X0206X
PAOT012136208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086X0206XAllopathic & Osteopathic PhysiciansSurgerySurgical Oncology
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA102920739Medicaid