Provider Demographics
NPI:1497748354
Name:LODGE, LARRY L (DPM)
Entity Type:Individual
Prefix:DR
First Name:LARRY
Middle Name:L
Last Name:LODGE
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 B ROUTE 73, SUITE 3
Mailing Address - Street 2:GARDEN STATE FOOT CARE
Mailing Address - City:VOORHEES
Mailing Address - State:NJ
Mailing Address - Zip Code:08043-9542
Mailing Address - Country:US
Mailing Address - Phone:856-753-1300
Mailing Address - Fax:856-768-2965
Practice Address - Street 1:200 ROUTE 73 STE 3
Practice Address - Street 2:
Practice Address - City:VOORHEES
Practice Address - State:NJ
Practice Address - Zip Code:08043-9542
Practice Address - Country:US
Practice Address - Phone:856-753-1300
Practice Address - Fax:856-768-2965
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-25
Last Update Date:2010-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MD002054213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ538006Medicaid
NJ538006Medicaid
NJT83604Medicare UPIN