Provider Demographics
NPI:1174776496
Name:WARIBOKO, JENNY VICTORIA (MD)
Entity type:Individual
Prefix:
First Name:JENNY
Middle Name:VICTORIA
Last Name:WARIBOKO
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 1:5130 SALEM AVE
Mailing Address - Street 2:
Mailing Address - City:TROTWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:45426-2042
Mailing Address - Country:US
Mailing Address - Phone:937-529-4443
Mailing Address - Fax:
Practice Address - Street 1:5130 SALEM AVE
Practice Address - Street 2:
Practice Address - City:TROTWOOD
Practice Address - State:OH
Practice Address - Zip Code:45426-2042
Practice Address - Country:US
Practice Address - Phone:937-529-4443
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-30
Last Update Date:2017-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH57.015536207R00000X, 208000000X
OH35.096373208M00000X, 208000000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0058547Medicaid
OHH054820Medicare PIN