MEDICARE: JEANNINE MISUTKA DODDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	012300	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1043412976
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JEANNINE MISUTKA DODDS

Provider Business Mailing Address
First Line	:	85 SOUTH WEST STREET
Second Line	:
City	:	HOMER
State	:	NY
Zip	:	13077-0000
Country	:	US
Telephone Number	:	607-753-3797
Fax Number	:	607-753-6677

Provider Business Practice Location Address
First Line	:	2809 CINCINNATUS RD
Second Line	:
City	:	CINCINNATUS
State	:	NY
Zip	:	13040-9685
Country	:	US
Telephone Number	:	607-863-3200
Fax Number	:	607-863-3455

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/04/2007
Last Update Date	:	04/28/2022

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