Provider Demographics
NPI:1417021494
Name:DODGE, GLENN (DPT)
Entity Type:Individual
Prefix:MR
First Name:GLENN
Middle Name:
Last Name:DODGE
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33648 APPLE VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:PARMA
Mailing Address - State:ID
Mailing Address - Zip Code:83660-6404
Mailing Address - Country:US
Mailing Address - Phone:208-484-1498
Mailing Address - Fax:541-889-4628
Practice Address - Street 1:49 NW 1ST ST STE 1
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:OR
Practice Address - Zip Code:97914-2468
Practice Address - Country:US
Practice Address - Phone:541-889-4550
Practice Address - Fax:541-889-4628
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-20
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3474225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR132628Medicare PIN