Provider Demographics
NPI:1740282607
Name:LAMENDOLA, JEROME
Entity type:Individual
Prefix:
First Name:JEROME
Middle Name:
Last Name:LAMENDOLA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30575 EUCLID AVE
Mailing Address - Street 2:
Mailing Address - City:WICKLIFFE
Mailing Address - State:OH
Mailing Address - Zip Code:44092-1037
Mailing Address - Country:US
Mailing Address - Phone:440-516-3776
Mailing Address - Fax:440-516-3783
Practice Address - Street 1:15810 DETROIT AVE
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:OH
Practice Address - Zip Code:44107-3711
Practice Address - Country:US
Practice Address - Phone:216-529-1800
Practice Address - Fax:216-529-3201
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-11
Last Update Date:2011-01-24
Deactivation Date:2006-03-22
Deactivation Code:
Reactivation Date:2006-03-27
Provider Licenses
StateLicense IDTaxonomies
OH36-00-2157-L213ES0103X
332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0551095Medicaid
OH1197120001Medicare NSC
OH0533572Medicare PIN
OH480005196Medicare PIN
OHP00875594Medicare PIN
OH0551095Medicaid
OH0533573Medicare PIN