=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619959582
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JEFFREY DAVID SNEDEKER MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/16/2005
-----------------------------------------------------
Last Update Date | 09/18/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10 GRAHAM RD W
-----------------------------------------------------
City | ITHACA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14850-1055
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 607-257-2188
-----------------------------------------------------
Fax | 607-266-7341
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10 GRAHAM RD W
-----------------------------------------------------
City | ITHACA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14850-1055
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 607-257-2188
-----------------------------------------------------
Fax | 607-266-7341
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | 198429
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2080P0208X
-----------------------------------------------------
Taxonomy Name | Pediatric Infectious Diseases Physician
-----------------------------------------------------
License Number | 198429
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------