Provider Demographics
NPI:1568470508
Name:LODGE, M (DPM)
Entity Type:Individual
Prefix:DR
First Name:M
Middle Name:
Last Name:LODGE
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1217 CURRY RD
Mailing Address - Street 2:
Mailing Address - City:ROTTERDAM
Mailing Address - State:NY
Mailing Address - Zip Code:12306-3707
Mailing Address - Country:US
Mailing Address - Phone:518-355-0043
Mailing Address - Fax:518-355-0053
Practice Address - Street 1:1217 CURRY RD
Practice Address - Street 2:
Practice Address - City:ROTTERDAM
Practice Address - State:NY
Practice Address - Zip Code:12306-3707
Practice Address - Country:US
Practice Address - Phone:518-355-0043
Practice Address - Fax:518-355-0053
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2009-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASC005680213ES0103X
NY006165213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYRB2149Medicare PIN