Provider Demographics
NPI:1962451922
Name:KORDYZON, JODI LYNN (OD)
Entity Type:Individual
Prefix:DR
First Name:JODI
Middle Name:LYNN
Last Name:KORDYZON
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 1:1427 WESTHAVEN DR
Mailing Address - Street 2:
Mailing Address - City:TECUMSEH
Mailing Address - State:MI
Mailing Address - Zip Code:49286-1645
Mailing Address - Country:US
Mailing Address - Phone:517-423-5612
Mailing Address - Fax:
Practice Address - Street 1:1400 W MAUMEE ST
Practice Address - Street 2:
Practice Address - City:ADRIAN
Practice Address - State:MI
Practice Address - Zip Code:49221-1804
Practice Address - Country:US
Practice Address - Phone:517-265-5444
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901004049152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4254842Medicaid
MI4254842Medicaid
MI67606006Medicare ID - Type Unspecified