Basic Information
| Provider Information | |||||||||
| NPI: | 1134394877 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | IDONIBOYE | ||||||||
| FirstName: | GERALDINE | ||||||||
| MiddleName: | JUMOGOLIMA | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | IDONIBOYE | ||||||||
| OtherFirstName: | JUMOGOLIMA | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 283 BUTLER RD | ||||||||
| Address2: | |||||||||
| City: | MOUNT GRETNA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 170646085 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7172738871 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 283 BUTLER RD | ||||||||
| Address2: | |||||||||
| City: | MOUNT GRETNA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 170646085 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7172738871 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/24/2008 | ||||||||
| LastUpdateDate: | 11/10/2014 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | MD438534 | PA | N | Other Service Providers | Specialist | 2084P0800X | MD438534 | PA | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
No ID Information.