Provider Demographics
NPI:1932690294
Name:JODY, NICOLE MARIE CLEMENTS (MD)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:MARIE CLEMENTS
Last Name:JODY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:MARIE
Other - Last Name:CLEMENTS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 776879
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6879
Mailing Address - Country:US
Mailing Address - Phone:502-559-9411
Mailing Address - Fax:502-272-5339
Practice Address - Street 1:2933 BRECKENRIDGE LN STE 102
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40220-1494
Practice Address - Country:US
Practice Address - Phone:502-588-9588
Practice Address - Fax:502-588-0554
Is Sole Proprietor?:No
Enumeration Date:2018-05-22
Last Update Date:2024-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZR76837207R00000X
KY59604207W00000X, 207WX0110X
CAA179129207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207WX0110XAllopathic & Osteopathic PhysiciansOphthalmologyPediatric Ophthalmology and Strabismus Specialist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmology