Provider Demographics
NPI:1689761454
Name:DOLAN, JEANNINE L (MD)
Entity Type:Individual
Prefix:DR
First Name:JEANNINE
Middle Name:L
Last Name:DOLAN
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:PO BOX 368
Mailing Address - Street 2:
Mailing Address - City:ONTARIO
Mailing Address - State:NY
Mailing Address - Zip Code:14519-0368
Mailing Address - Country:US
Mailing Address - Phone:315-524-2881
Mailing Address - Fax:315-524-2231
Practice Address - Street 1:5973 WALWORTH RD
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:NY
Practice Address - Zip Code:14519-9592
Practice Address - Country:US
Practice Address - Phone:315-524-2881
Practice Address - Fax:315-524-2231
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2009-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY205850207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY080164433OtherRAILROAD MEDICARE PTAN (PIN)