Healthcare Provider Details

I. General information

NPI: 1528500154
Provider Name (Legal Business Name): DR. JODI CARBONE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/14/2016
Last Update Date: 11/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

212 W EDISON RD SUITE F
MISHAWAKA IN
46545-8301
US

IV. Provider business mailing address

212 W EDISON RD SUITE F
MISHAWAKA IN
46545-8301
US

V. Phone/Fax

Practice location:
  • Phone: 574-257-0621
  • Fax: 574-257-0641
Mailing address:
  • Phone: 574-257-0621
  • Fax: 574-257-0641

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number01041178A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: