Provider Demographics
NPI:1346342193
Name:HODGE, WAVELL CONSTANTINE (MD)
Entity Type:Individual
Prefix:DR
First Name:WAVELL
Middle Name:CONSTANTINE
Last Name:HODGE
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 1:13210 CABINWOOD DR
Mailing Address - Street 2:
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20904-3128
Mailing Address - Country:US
Mailing Address - Phone:301-384-2011
Mailing Address - Fax:
Practice Address - Street 1:2094 ALBANY POST RD
Practice Address - Street 2:
Practice Address - City:MONTROSE
Practice Address - State:NY
Practice Address - Zip Code:10548-1454
Practice Address - Country:US
Practice Address - Phone:914-760-1622
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD31383207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine