Provider Demographics
NPI:1346239571
Name:AMODEO, JEFFREY L (MD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:L
Last Name:AMODEO
Suffix:
Gender:M
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:PO BOX 1557
Mailing Address - Street 2:
Mailing Address - City:MARTINSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46151-0557
Mailing Address - Country:US
Mailing Address - Phone:765-349-4600
Mailing Address - Fax:765-349-6590
Practice Address - Street 1:2200 JOHN R WOODEN DR
Practice Address - Street 2:
Practice Address - City:MARTINSVILLE
Practice Address - State:IN
Practice Address - Zip Code:46151-1863
Practice Address - Country:US
Practice Address - Phone:765-342-5415
Practice Address - Fax:765-342-3415
Is Sole Proprietor?:No
Enumeration Date:2005-10-20
Last Update Date:2012-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY234562208600000X
IN01068850A208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02656499Medicaid
NY1712914OtherIHA
IN01068850AOtherIN STATE LICENSE
NY164405FLOtherPREFERRED CARE
NY050802000019OtherFIDELIS
NY000528151001OtherBC/BS
NY00027200501OtherUNIVERA
NY1712914OtherIHA
NY164405FLOtherPREFERRED CARE
NYRB5098Medicare PIN