Provider Demographics
NPI:1184625949
Name:YODER, JEFFERY A (MD)
Entity type:Individual
Prefix:
First Name:JEFFERY
Middle Name:A
Last Name:YODER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11109 PARKVIEW PLAZA DR # 117
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1701
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11141 PARKVIEW PLAZA DR STE 305
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845-1715
Practice Address - Country:US
Practice Address - Phone:260-484-9611
Practice Address - Fax:260-484-1004
Is Sole Proprietor?:No
Enumeration Date:2005-08-02
Last Update Date:2021-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01040292A208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI103410352Medicaid
OH0998121Medicaid
IN100082270Medicaid
IN020026956Medicare PIN
OH0998121Medicaid
IN260100MMedicare PIN
MI103410352Medicaid
IN667640FMedicare PIN
IN149110PMedicare PIN