Provider Demographics
NPI:1821179904
Name:SUJOVOLSKY, JEANNETTE A (DO)
Entity Type:Individual
Prefix:DR
First Name:JEANNETTE
Middle Name:A
Last Name:SUJOVOLSKY
Suffix:
Gender:F
Credentials:DO
Other - Prefix:DR
Other - First Name:JEANNETTE
Other - Middle Name:
Other - Last Name:AGUILAR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:1116 43RD ST
Mailing Address - Street 2:
Mailing Address - City:NORTH BERGEN
Mailing Address - State:NJ
Mailing Address - Zip Code:07047-2712
Mailing Address - Country:US
Mailing Address - Phone:201-330-2632
Mailing Address - Fax:201-330-2638
Practice Address - Street 1:1116 43RD ST
Practice Address - Street 2:
Practice Address - City:NORTH BERGEN
Practice Address - State:NJ
Practice Address - Zip Code:07047-2712
Practice Address - Country:US
Practice Address - Phone:201-330-2632
Practice Address - Fax:201-330-2638
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2015-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB08580200207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ08BBRLVOtherMEDICARE
024647Medicare PIN
VA00X847P01OtherMEDICARE
NJ08BBRLVOtherMEDICARE