Provider Demographics
NPI:1194810242
Name:GONGOLA, JENNA LOUISE (OD)
Entity type:Individual
Prefix:
First Name:JENNA
Middle Name:LOUISE
Last Name:GONGOLA
Suffix:
Gender:F
Credentials:OD
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 1489
Mailing Address - Street 2:
Mailing Address - City:ELKINS
Mailing Address - State:WV
Mailing Address - Zip Code:26241
Mailing Address - Country:US
Mailing Address - Phone:304-636-3887
Mailing Address - Fax:304-636-0538
Practice Address - Street 1:RT 250 219 CHENOWETH CREEK RD
Practice Address - Street 2:
Practice Address - City:ELKINS
Practice Address - State:WV
Practice Address - Zip Code:26241
Practice Address - Country:US
Practice Address - Phone:304-636-3887
Practice Address - Fax:304-636-0538
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2010-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV93800152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0149877000Medicaid
WV0149877000Medicaid
WVGO0793504Medicare PIN