Healthcare Provider Details

I. General information

NPI: 1326047085
Provider Name (Legal Business Name): JODI LYNN LONG DPM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2005
Last Update Date: 06/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10701 EAST BLVD
CLEVELAND OH
44106
US

IV. Provider business mailing address

2179 STATE ROUTE 193 N
JEFFERSON OH
44047-8457
US

V. Phone/Fax

Practice location:
  • Phone: 216-791-2300
  • Fax:
Mailing address:
  • Phone: 440-796-6365
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number36.003386
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: