Provider Demographics
NPI:1184835696
Name:GRANDOMINICO-BRADFORD, JODI (MD)
Entity type:Individual
Prefix:
First Name:JODI
Middle Name:
Last Name:GRANDOMINICO-BRADFORD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JODI
Other - Middle Name:
Other - Last Name:GRANDOMINICO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:700 ACKERMAN RD STE 2120
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43202-1559
Mailing Address - Country:US
Mailing Address - Phone:614-293-2594
Mailing Address - Fax:
Practice Address - Street 1:3900 STONERIDGE LN STE B
Practice Address - Street 2:
Practice Address - City:DUBLIN
Practice Address - State:OH
Practice Address - Zip Code:43017-2289
Practice Address - Country:US
Practice Address - Phone:614-293-0080
Practice Address - Fax:614-293-0077
Is Sole Proprietor?:No
Enumeration Date:2007-05-25
Last Update Date:2021-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35093125207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2996932Medicaid
4263081Medicare PIN