Provider Demographics
NPI:1053318444
Name:DODGE, JAMES T (DO)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:T
Last Name:DODGE
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 1:919B CHAMBERS BLVD
Mailing Address - Street 2:
Mailing Address - City:BARDSTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:40004-2526
Mailing Address - Country:US
Mailing Address - Phone:502-349-1411
Mailing Address - Fax:502-349-0980
Practice Address - Street 1:919B CHAMBERS BLVD
Practice Address - Street 2:
Practice Address - City:BARDSTOWN
Practice Address - State:KY
Practice Address - Zip Code:40004-2526
Practice Address - Country:US
Practice Address - Phone:502-349-1411
Practice Address - Fax:502-349-0980
Is Sole Proprietor?:No
Enumeration Date:2005-06-30
Last Update Date:2011-09-15
Deactivation Date:2006-03-20
Deactivation Code:
Reactivation Date:2006-06-27
Provider Licenses
StateLicense IDTaxonomies
KY02609207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1165473OtherPASSPORT
KY000000298318OtherANTHEM BC/BS
KYK005340Medicare PIN
KY000000298318OtherANTHEM BC/BS