Provider Demographics
NPI:1043412976
Name:DODDS, JEANNINE MISUTKA
Entity Type:Individual
Prefix:
First Name:JEANNINE
Middle Name:MISUTKA
Last Name:DODDS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:85 SOUTH WEST STREET
Mailing Address - Street 2:
Mailing Address - City:HOMER
Mailing Address - State:NY
Mailing Address - Zip Code:13077-0000
Mailing Address - Country:US
Mailing Address - Phone:607-753-3797
Mailing Address - Fax:607-753-6677
Practice Address - Street 1:2809 CINCINNATUS RD
Practice Address - Street 2:
Practice Address - City:CINCINNATUS
Practice Address - State:NY
Practice Address - Zip Code:13040-9685
Practice Address - Country:US
Practice Address - Phone:607-863-3200
Practice Address - Fax:607-863-3455
Is Sole Proprietor?:No
Enumeration Date:2007-06-04
Last Update Date:2022-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY012300363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03433754Medicaid