Provider Demographics
NPI:1073595054
Name:HODSON, MARY ELISE (MD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:ELISE
Last Name:HODSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 781076
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48278-1076
Mailing Address - Country:US
Mailing Address - Phone:317-528-4800
Mailing Address - Fax:317-865-1479
Practice Address - Street 1:900 AVERITT RD
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:IN
Practice Address - Zip Code:46143-9540
Practice Address - Country:US
Practice Address - Phone:317-865-3115
Practice Address - Fax:317-885-1429
Is Sole Proprietor?:No
Enumeration Date:2005-11-16
Last Update Date:2023-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01039268A208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200002380BMedicaid
322390Medicare ID - Type Unspecified
IN200002380BMedicaid