Provider Demographics
NPI:1164439725
Name:HODGMAN, NICHOLAS W (MD)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:W
Last Name:HODGMAN
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 1:3340 E GOLDSTONE DR
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642
Mailing Address - Country:US
Mailing Address - Phone:208-302-0200
Mailing Address - Fax:208-302-0255
Practice Address - Street 1:4424 E FLAMINGO AVE
Practice Address - Street 2:STE 300
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83687
Practice Address - Country:US
Practice Address - Phone:208-302-0200
Practice Address - Fax:208-302-0255
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2019-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA38352207RC0000X
IDM-14705207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA3899OtherRR MEDICARE GROUP
POO731202OtherRR MEDICARE INDIV
71960OtherMEDICARE GROUP