Provider Demographics
NPI:1730299603
Name:CLOUSE, JODI S (MD)
Entity Type:Individual
Prefix:
First Name:JODI
Middle Name:S
Last Name:CLOUSE
Suffix:
Gender:F
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 158
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:IN
Mailing Address - Zip Code:46567
Mailing Address - Country:US
Mailing Address - Phone:574-457-5701
Mailing Address - Fax:574-457-5609
Practice Address - Street 1:1033 NORTH INDIANA AVENUE
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:IN
Practice Address - Zip Code:46567
Practice Address - Country:US
Practice Address - Phone:574-457-5701
Practice Address - Fax:574-457-5609
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2019-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMD16489207Q00000X
VA0101266076207Q00000X
NC2019-00100207Q00000X
IN01050876207Q00000X
TXS0441207Q00000X
MN65197207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200187460Medicaid
IN226240BMedicare PIN
H15159Medicare UPIN
184520004Medicare PIN