Provider Demographics
NPI:1619905429
Name:DODGE, JAMES THEODORE JR (MD)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:THEODORE
Last Name:DODGE
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:J
Other - Middle Name:THEODORE
Other - Last Name:DODGE
Other - Suffix:JR
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:820 N CHELAN AVE
Mailing Address - Street 2:
Mailing Address - City:WENATCHEE
Mailing Address - State:WA
Mailing Address - Zip Code:98801-2028
Mailing Address - Country:US
Mailing Address - Phone:509-663-8711
Mailing Address - Fax:
Practice Address - Street 1:1201 S MILLER ST STE A
Practice Address - Street 2:
Practice Address - City:WENATCHEE
Practice Address - State:WA
Practice Address - Zip Code:98801-3201
Practice Address - Country:US
Practice Address - Phone:509-663-8711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2015-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00031058207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA315914OtherWVH LNI
WAP01256388OtherRR MEDICARE WVH
WA1619905429Medicaid
WAP01256388OtherRR MEDICARE WVH
WA315914OtherL&I POST 7/21/13