Provider Demographics
NPI:1720279128
Name:SROF, JODY L (FNP)
Entity Type:Individual
Prefix:
First Name:JODY
Middle Name:L
Last Name:SROF
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1627 E BRISTOL ST
Mailing Address - Street 2:
Mailing Address - City:ELKHART
Mailing Address - State:IN
Mailing Address - Zip Code:46514-3817
Mailing Address - Country:US
Mailing Address - Phone:574-262-0313
Mailing Address - Fax:574-262-8163
Practice Address - Street 1:1627 E BRISTOL ST
Practice Address - Street 2:
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46514-3817
Practice Address - Country:US
Practice Address - Phone:574-262-0313
Practice Address - Fax:574-262-8163
Is Sole Proprietor?:No
Enumeration Date:2007-08-09
Last Update Date:2007-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN70000044A208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics