Provider Demographics
NPI:1629037189
Name:TRAUB, JODI (OD)
Entity Type:Individual
Prefix:DR
First Name:JODI
Middle Name:
Last Name:TRAUB
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5716 W CLAY ST
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57106-0297
Mailing Address - Country:US
Mailing Address - Phone:605-367-3962
Mailing Address - Fax:
Practice Address - Street 1:3401 S KELLEY AVE
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57106-6300
Practice Address - Country:US
Practice Address - Phone:605-361-1680
Practice Address - Fax:605-361-1590
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDT-500152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD9202723Medicaid
SDU-35725Medicare UPIN
SD100685Medicare ID - Type Unspecified