Provider Demographics
NPI:1609851351
Name:HODGES, STANLEY M (MD)
Entity Type:Individual
Prefix:
First Name:STANLEY
Middle Name:M
Last Name:HODGES
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 E SPRINGBROOK DR
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37601-1761
Mailing Address - Country:US
Mailing Address - Phone:423-794-5520
Mailing Address - Fax:423-282-0720
Practice Address - Street 1:301 MED TECH PKWY
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-2630
Practice Address - Country:US
Practice Address - Phone:423-794-5520
Practice Address - Fax:423-282-0720
Is Sole Proprietor?:No
Enumeration Date:2005-12-14
Last Update Date:2020-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN35007207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3861671Medicaid
TNTN01Y9OtherJOHN DEERE
VA1609851351Medicaid
TN4124140OtherBCBS OF TENNESSEE
TNP00384556OtherRAILROAD MEDICARE
TNQ002682Medicaid
TNTN01Y9OtherBCBS OF TN
TN3861679Medicaid
KY6406054400Medicaid
TN4346248OtherBCBSTN
TN4346327OtherBCBSTN
TNP00384556OtherRAILROAD MEDICARE
TN4346248OtherBCBSTN
TN103I113344Medicare PIN