Provider Demographics
NPI:1174020317
Name:HODGE, DOUGLAS BRYANT (CO)
Entity Type:Individual
Prefix:MR
First Name:DOUGLAS
Middle Name:BRYANT
Last Name:HODGE
Suffix:
Gender:M
Credentials:CO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9591 VALPARAISO CT
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46268-1130
Mailing Address - Country:US
Mailing Address - Phone:317-218-4270
Mailing Address - Fax:317-218-4271
Practice Address - Street 1:9591 VALPARAISO CT
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46268-1130
Practice Address - Country:US
Practice Address - Phone:317-218-4270
Practice Address - Fax:317-218-4271
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-12
Last Update Date:2018-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DECO001774222Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist