Provider Demographics
NPI:1811135684
Name:WALLIS, JODI BETH (DO)
Entity type:Individual
Prefix:
First Name:JODI
Middle Name:BETH
Last Name:WALLIS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:DR
Other - First Name:JODI
Other - Middle Name:BETH
Other - Last Name:KAPLAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:725 IRVING AVE
Mailing Address - Street 2:STE 600
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13210-1603
Mailing Address - Country:US
Mailing Address - Phone:315-464-5162
Mailing Address - Fax:315-464-4613
Practice Address - Street 1:725 IRVING AVE
Practice Address - Street 2:STE 600
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13210-1603
Practice Address - Country:US
Practice Address - Phone:315-464-5162
Practice Address - Fax:315-464-4613
Is Sole Proprietor?:No
Enumeration Date:2009-02-01
Last Update Date:2013-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY271804207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03657994Medicaid
NY03657994Medicaid