Basic Information
| Provider Information | |||||||||
| NPI: | 1982607727 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SUDE | ||||||||
| FirstName: | JEROME | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | O.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 207170 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 753202117 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6362004393 | ||||||||
| FaxNumber: | 6365270766 | ||||||||
| Practice Location | |||||||||
| Address1: | 3510 MANCHESTER RD | ||||||||
| Address2: | |||||||||
| City: | COVENTRY TOWNSHIP | ||||||||
| State: | OH | ||||||||
| PostalCode: | 443191415 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3307532100 | ||||||||
| FaxNumber: | 3306337165 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/24/2005 | ||||||||
| LastUpdateDate: | 06/08/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 06/08/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 3046/T812 | OH | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 1418274 | 01 | OH | UNITED HEALTHCARE | OTHER | 410022025 | 01 | OH | RAILROAD MEDICARE | OTHER | 0655759 | 01 | OH | AETNA HMO | OTHER | 341572960B | 01 | OH | SUMMA | OTHER | 728946 | 01 | OH | BUCKEYE | OTHER | 000000134329 | 01 | OH | ANTHEM | OTHER | 4338408 | 01 | OH | AETNA PPO | OTHER | 0505046 | 05 | OH | MEDICAID |