Provider Demographics
NPI:1164426771
Name:HODSON, GREGORY R (MD)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:R
Last Name:HODSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2225 TETON PLZ
Mailing Address - Street 2:STE B
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-6494
Mailing Address - Country:US
Mailing Address - Phone:208-524-4660
Mailing Address - Fax:208-524-4617
Practice Address - Street 1:2225 TETON PLZ
Practice Address - Street 2:STE B
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-6494
Practice Address - Country:US
Practice Address - Phone:208-524-4660
Practice Address - Fax:208-524-4617
Is Sole Proprietor?:No
Enumeration Date:2005-06-10
Last Update Date:2016-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM64792086S0129X
IN01076326A208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000001021963OtherANTHEM PROVIDER NUMBER UNDER TIN 35-2030653
IN201352320Medicaid
IN201352320Medicaid
IN000001021963OtherANTHEM PROVIDER NUMBER UNDER TIN 35-2030653
IN264430395Medicare PIN