Provider Demographics
NPI:1093834012
Name:HODGES, LISA GAYE (DC)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:GAYE
Last Name:HODGES
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:609 RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:MUNSTER
Mailing Address - State:IN
Mailing Address - Zip Code:46321-1609
Mailing Address - Country:US
Mailing Address - Phone:219-836-3952
Mailing Address - Fax:219-836-3054
Practice Address - Street 1:609 RIDGE RD
Practice Address - Street 2:
Practice Address - City:MUNSTER
Practice Address - State:IN
Practice Address - Zip Code:46321-1609
Practice Address - Country:US
Practice Address - Phone:219-836-3952
Practice Address - Fax:219-836-3054
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-29
Last Update Date:2007-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN08001421A111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN2004656508Medicaid
U36711Medicare UPIN
IN183570Medicare ID - Type Unspecified