Provider Demographics
NPI:1497740898
Name:HODGINI, TIMOTHY J (DO)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:J
Last Name:HODGINI
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12207 CREE CT
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46814-9162
Mailing Address - Country:US
Mailing Address - Phone:260-602-4892
Mailing Address - Fax:260-625-5732
Practice Address - Street 1:12207 CREE CT
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46814-9162
Practice Address - Country:US
Practice Address - Phone:260-602-4892
Practice Address - Fax:260-625-5732
Is Sole Proprietor?:No
Enumeration Date:2005-09-13
Last Update Date:2012-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02001358A207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000197634OtherANTHEM
OH2517173Medicaid
000000008051OtherMPLAN
MI114874534Medicaid
IN100462990Medicaid
930112227Medicare ID - Type UnspecifiedRR MEDICARE
000000008051OtherMPLAN
OH2517173Medicaid