Basic Information
Provider Information | |||||||||
NPI: | 1427028596 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | KODISH-WACHS | ||||||||
FirstName: | JODI | ||||||||
MiddleName: | E | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | KODISH | ||||||||
OtherFirstName: | JODI | ||||||||
OtherMiddleName: | E | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 635 | ||||||||
Address2: |   | ||||||||
City: | BELLMAWR | ||||||||
State: | NJ | ||||||||
PostalCode: | 080990635 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8567705772 | ||||||||
FaxNumber: | 8565662797 | ||||||||
Practice Location | |||||||||
Address1: | 42 LAUREL RD E | ||||||||
Address2: | UDP #1700 | ||||||||
City: | STRATFORD | ||||||||
State: | NJ | ||||||||
PostalCode: | 080841354 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8565667010 | ||||||||
FaxNumber: | 8565666956 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/23/2006 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | X | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | MA07556200 | NJ | Y |   | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |   |
ID Information
ID | Type | State | Issuer | Description | 0030813 | 05 | NJ |   | MEDICAID |