Provider Demographics
NPI:1124429196
Name:GOTTARDI, JODI
Entity type:Individual
Prefix:
First Name:JODI
Middle Name:
Last Name:GOTTARDI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 WHEELING AVE
Mailing Address - Street 2:
Mailing Address - City:GLEN DALE
Mailing Address - State:WV
Mailing Address - Zip Code:26038-1660
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:800 WHEELING AVE
Practice Address - Street 2:
Practice Address - City:GLEN DALE
Practice Address - State:WV
Practice Address - Zip Code:26038-1660
Practice Address - Country:US
Practice Address - Phone:304-845-3211
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-10
Last Update Date:2023-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50-004078363A00000X
WV2036363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant