Provider Demographics
NPI:1760669584
Name:JODY, MICHAEL Z (LP, MA, MA)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:Z
Last Name:JODY
Suffix:
Gender:M
Credentials:LP, MA, MA
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 1260
Mailing Address - Street 2:
Mailing Address - City:AMAGANSETT
Mailing Address - State:NY
Mailing Address - Zip Code:11930-1260
Mailing Address - Country:US
Mailing Address - Phone:917-825-8565
Mailing Address - Fax:
Practice Address - Street 1:530 MONTAUK HIGHWAY,
Practice Address - Street 2:HAROLD MCMAHON MEDICAL CENTER
Practice Address - City:AMAGANSETT
Practice Address - State:NY
Practice Address - Zip Code:11930-1260
Practice Address - Country:US
Practice Address - Phone:917-825-8565
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-23
Last Update Date:2010-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY000386102L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes102L00000XBehavioral Health & Social Service ProvidersPsychoanalyst