Provider Demographics
NPI:1508848284
Name:FOX, JODI L (MD)
Entity Type:Individual
Prefix:DR
First Name:JODI
Middle Name:L
Last Name:FOX
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JODI
Other - Middle Name:L
Other - Last Name:BRYANT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:3411 PROFESSIONAL PARK DR
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IL
Mailing Address - Zip Code:62959-6394
Mailing Address - Country:US
Mailing Address - Phone:618-997-2161
Mailing Address - Fax:
Practice Address - Street 1:3411 PROFESSIONAL PARK DR
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IL
Practice Address - Zip Code:62959-6394
Practice Address - Country:US
Practice Address - Phone:618-997-2161
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-17
Last Update Date:2023-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036105537207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00296626OtherRR MEDICARE
H68003Medicare UPIN
P00296626OtherRR MEDICARE