Provider Demographics
NPI: | 1497736102 |
---|---|
Name: | HUMMEL, JODI MARIE (OD) |
Entity Type: | Individual |
Prefix: | DR |
First Name: | JODI |
Middle Name: | MARIE |
Last Name: | HUMMEL |
Suffix: | |
Gender: | F |
Credentials: | OD |
Other - Prefix: | DR |
Other - First Name: | JODI |
Other - Middle Name: | MARIE |
Other - Last Name: | HALSEY |
Other - Suffix: | |
Other - Last Name Type: | Former Name |
Other - Credentials: | |
Mailing Address - Street 1: | 3830 W FRONT ST |
Mailing Address - Street 2: | |
Mailing Address - City: | TRAVERSE CITY |
Mailing Address - State: | MI |
Mailing Address - Zip Code: | 49684-8153 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 231-929-3888 |
Mailing Address - Fax: | 231-929-4365 |
Practice Address - Street 1: | 3830 W FRONT ST |
Practice Address - Street 2: | |
Practice Address - City: | TRAVERSE CITY |
Practice Address - State: | MI |
Practice Address - Zip Code: | 49684-8153 |
Practice Address - Country: | US |
Practice Address - Phone: | 231-929-3888 |
Practice Address - Fax: | 231-929-4365 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2005-11-09 |
Last Update Date: | 2010-01-15 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
MI | 4901004107 | 152W00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 152W00000X | Eye and Vision Services Providers | Optometrist |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
MI | 944976991 | Medicaid | |
MI | 900B86347 | Other | BCBS |
MI | 1020070001 | Other | DMERC REG B |
MI | P00396057 | Medicare PIN | |
MI | CN1586 | Medicare PIN | |
MI | 0B86347003 | Medicare PIN |