Provider Demographics
NPI:1982607727
Name:SUDE, JEROME (OD)
Entity Type:Individual
Prefix:DR
First Name:JEROME
Middle Name:
Last Name:SUDE
Suffix:
Gender:M
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:PO BOX 207170
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75320-2117
Mailing Address - Country:US
Mailing Address - Phone:636-200-4393
Mailing Address - Fax:636-527-0766
Practice Address - Street 1:3510 MANCHESTER RD
Practice Address - Street 2:
Practice Address - City:COVENTRY TOWNSHIP
Practice Address - State:OH
Practice Address - Zip Code:44319-1415
Practice Address - Country:US
Practice Address - Phone:330-753-2100
Practice Address - Fax:330-633-7165
Is Sole Proprietor?:No
Enumeration Date:2005-05-24
Last Update Date:2021-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3046/T812152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1418274OtherUNITED HEALTHCARE
OH410022025OtherRAILROAD MEDICARE
OH0655759OtherAETNA HMO
OH341572960BOtherSUMMA
OH728946OtherBUCKEYE
OH000000134329OtherANTHEM
OH4338408OtherAETNA PPO
OH0505046Medicaid
OH4338408OtherAETNA PPO