Provider Demographics
NPI:1205035607
Name:HODGE, JACQUELINE CELESTE (MD)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:CELESTE
Last Name:HODGE
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:PORZELLANGASSE 19/2/1
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VIENNA
Mailing Address - Zip Code:1090
Mailing Address - Country:AT
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5001 STATESMAN DR
Practice Address - Street 2:C/O STAFFCARE, INC.
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75063-2414
Practice Address - Country:US
Practice Address - Phone:800-685-2272
Practice Address - Fax:972-983-0254
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-16
Last Update Date:2007-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1718212085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY171821OtherMEDICAL LICENSE
MO2005025948OtherMEDICAL LICENSE