Provider Demographics
NPI:1760615447
Name:KREISER, JUANITA MARIE (DO)
Entity Type:Individual
Prefix:
First Name:JUANITA
Middle Name:MARIE
Last Name:KREISER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:JUANITA
Other - Middle Name:MARIE
Other - Last Name:LEIBOLD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7 DOCK HILL RD
Mailing Address - Street 2:
Mailing Address - City:MIDDLEBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17842-8910
Mailing Address - Country:US
Mailing Address - Phone:570-837-2123
Mailing Address - Fax:570-837-2185
Practice Address - Street 1:4830 LONDONDERRY RD
Practice Address - Street 2:
Practice Address - City:HARRISBURG
Practice Address - State:PA
Practice Address - Zip Code:17109-5207
Practice Address - Country:US
Practice Address - Phone:717-657-2595
Practice Address - Fax:717-657-3091
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-28
Last Update Date:2022-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS051066207R00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1026934130001Medicaid
PA226742F6KMedicare PIN