Provider Demographics
NPI:1114076650
Name:DODGE, RITA JOSEPHINE (MD)
Entity Type:Individual
Prefix:
First Name:RITA
Middle Name:JOSEPHINE
Last Name:DODGE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2019 GALISTEO ST
Mailing Address - Street 2:SUITE N9A
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505
Mailing Address - Country:US
Mailing Address - Phone:505-988-1930
Mailing Address - Fax:
Practice Address - Street 1:2019 GALISTEO ST
Practice Address - Street 2:SUITE N9A
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505
Practice Address - Country:US
Practice Address - Phone:505-988-1930
Practice Address - Fax:505-982-9931
Is Sole Proprietor?:No
Enumeration Date:2007-01-10
Last Update Date:2011-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM20030007207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM32405227Medicaid
NM32405227Medicaid
H79604Medicare UPIN