Provider Demographics
NPI:1558810309
Name:HODGE, JAMES (AG-ANCP-BC)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:
Last Name:HODGE
Suffix:
Gender:M
Credentials:AG-ANCP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2609 AMATI DRIVE
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34741
Mailing Address - Country:US
Mailing Address - Phone:410-608-5376
Mailing Address - Fax:
Practice Address - Street 1:1350 HICKORY ST
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-3224
Practice Address - Country:US
Practice Address - Phone:321-434-4225
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-21
Last Update Date:2022-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9461696363LA2100X
DELP-0000348363LA2100X
MDR192286363LA2100X
CT008372363LA2100X
FLAPRN9461696363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute CareGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP2257OtherMEDICARE HF
FL022631800Medicaid
CT008372OtherCT LIC