Provider Demographics
NPI:1780676353
Name:CANCINO, JENNIFER (MD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:CANCINO
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 1110
Mailing Address - Street 2:
Mailing Address - City:UNION BRIDGE
Mailing Address - State:MD
Mailing Address - Zip Code:21791-0579
Mailing Address - Country:US
Mailing Address - Phone:410-775-2622
Mailing Address - Fax:410-775-2050
Practice Address - Street 1:7211 BANK CT
Practice Address - Street 2:
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21703-8483
Practice Address - Country:US
Practice Address - Phone:240-215-6370
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-18
Last Update Date:2019-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0058038207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
W590-0003OtherCAREFIRST BCBS GHMSI
613037-01OtherCAREFIRST BCBS MARYLAND
1989337OtherUNITED
2600321OtherAETNA PVN
MDH31226Medicare UPIN
2600321OtherAETNA PVN