Provider Demographics
NPI:1477599306
Name:DODGE, CLINTON S (DC)
Entity Type:Individual
Prefix:DR
First Name:CLINTON
Middle Name:S
Last Name:DODGE
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8902 N MERIDIAN ST STE 101
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46260-5306
Mailing Address - Country:US
Mailing Address - Phone:317-848-8048
Mailing Address - Fax:
Practice Address - Street 1:279 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:BATESVILLE
Practice Address - State:IN
Practice Address - Zip Code:47006-8917
Practice Address - Country:US
Practice Address - Phone:812-932-3999
Practice Address - Fax:812-932-3998
Is Sole Proprietor?:No
Enumeration Date:2006-06-20
Last Update Date:2020-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN08002136A111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN233600AMedicare ID - Type Unspecified
INV07692Medicare UPIN