Provider Demographics
NPI:1538125885
Name:JESSE, MICHAEL LEO (DO)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:LEO
Last Name:JESSE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32800 LORAIN RD STE 2100
Mailing Address - Street 2:
Mailing Address - City:NORTH RIDGEVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:44039-3430
Mailing Address - Country:US
Mailing Address - Phone:440-235-3711
Mailing Address - Fax:
Practice Address - Street 1:7856 BROOKSIDE DR
Practice Address - Street 2:
Practice Address - City:OLMSTED FALLS
Practice Address - State:OH
Practice Address - Zip Code:44138-1653
Practice Address - Country:US
Practice Address - Phone:440-235-3711
Practice Address - Fax:440-235-3786
Is Sole Proprietor?:No
Enumeration Date:2006-04-25
Last Update Date:2020-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34003567207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH341842373008OtherBWC
OH711484Medicaid
A17538Medicare UPIN
OH711484Medicaid