Provider Demographics
NPI:1518933902
Name:HODGES, HOLLY JO L (MD)
Entity Type:Individual
Prefix:DR
First Name:HOLLY JO
Middle Name:L
Last Name:HODGES
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:HOLLY JO
Other - Middle Name:
Other - Last Name:LEDGERWOOD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:4040 N. SHASTA LOOP
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97405
Mailing Address - Country:US
Mailing Address - Phone:541-343-0079
Mailing Address - Fax:541-636-3780
Practice Address - Street 1:2995 RYAN DRIVE, SE
Practice Address - Street 2:SUITE #200
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301
Practice Address - Country:US
Practice Address - Phone:503-371-7701
Practice Address - Fax:503-371-8046
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-24
Last Update Date:2014-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD19870207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR082201Medicaid
OR082201Medicaid
OR0000BLBWVMedicare ID - Type UnspecifiedNORIDIAN BILLING NUMBER