Basic Information
| Provider Information | |||||||||
| NPI: | 1043412976 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DODDS | ||||||||
| FirstName: | JEANNINE | ||||||||
| MiddleName: | MISUTKA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 85 SOUTH WEST STREET | ||||||||
| Address2: | |||||||||
| City: | HOMER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 130770000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6077533797 | ||||||||
| FaxNumber: | 6077536677 | ||||||||
| Practice Location | |||||||||
| Address1: | 2809 CINCINNATUS RD | ||||||||
| Address2: | |||||||||
| City: | CINCINNATUS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 130409685 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6078633200 | ||||||||
| FaxNumber: | 6078633455 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/04/2007 | ||||||||
| LastUpdateDate: | 04/28/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/28/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 012300 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 03433754 | 05 | NY | MEDICAID |