Provider Demographics
NPI:1215016209
Name:HODGE, REVA (EDD)
Entity Type:Individual
Prefix:DR
First Name:REVA
Middle Name:
Last Name:HODGE
Suffix:
Gender:F
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12650 W. COUNTY ROAD
Mailing Address - Street 2:
Mailing Address - City:GASTON
Mailing Address - State:IN
Mailing Address - Zip Code:47342
Mailing Address - Country:US
Mailing Address - Phone:765-358-4649
Mailing Address - Fax:765-358-4650
Practice Address - Street 1:12650 W. COUNTY ROAD 1100 N.
Practice Address - Street 2:
Practice Address - City:GASTON
Practice Address - State:IN
Practice Address - Zip Code:47342
Practice Address - Country:US
Practice Address - Phone:765-358-4649
Practice Address - Fax:765-358-4650
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NONE174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist