Provider Demographics
NPI:1992700371
Name:KOH, JEANMARIE ATIENZA (MD)
Entity type:Individual
Prefix:
First Name:JEANMARIE
Middle Name:ATIENZA
Last Name:KOH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1086 FRANKLIN ST
Mailing Address - Street 2:
Mailing Address - City:JOHNSTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:15905-4305
Mailing Address - Country:US
Mailing Address - Phone:814-534-1555
Mailing Address - Fax:814-535-8720
Practice Address - Street 1:1940 WILLIAM PENN AVE
Practice Address - Street 2:
Practice Address - City:CONEMAUGH
Practice Address - State:PA
Practice Address - Zip Code:15909-1609
Practice Address - Country:US
Practice Address - Phone:814-322-1519
Practice Address - Fax:814-322-1454
Is Sole Proprietor?:No
Enumeration Date:2005-06-14
Last Update Date:2019-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD052897L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001469440Medicaid
PA056289Medicare ID - Type Unspecified