Provider Demographics
NPI:1548558935
Name:HODGE, AMANDA M (OD)
Entity Type:Individual
Prefix:DR
First Name:AMANDA
Middle Name:M
Last Name:HODGE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:123 LOCUST ST
Mailing Address - Street 2:
Mailing Address - City:ALLEGAN
Mailing Address - State:MI
Mailing Address - Zip Code:49010-1301
Mailing Address - Country:US
Mailing Address - Phone:269-673-5100
Mailing Address - Fax:269-673-1806
Practice Address - Street 1:123 LOCUST ST
Practice Address - Street 2:
Practice Address - City:ALLEGAN
Practice Address - State:MI
Practice Address - Zip Code:49010-1301
Practice Address - Country:US
Practice Address - Phone:269-673-5100
Practice Address - Fax:269-673-1806
Is Sole Proprietor?:No
Enumeration Date:2011-07-19
Last Update Date:2011-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI490100462152W00000X
MI4901004652152WV0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIM92240004Medicare PIN