Provider Demographics
NPI:1629076559
Name:DODSON, KEVIN C
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:C
Last Name:DODSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1620 9TH ST
Mailing Address - Street 2:
Mailing Address - City:EAST MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61244-2120
Mailing Address - Country:US
Mailing Address - Phone:309-755-3809
Mailing Address - Fax:309-755-3860
Practice Address - Street 1:1620 9TH ST
Practice Address - Street 2:
Practice Address - City:EAST MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61244-2120
Practice Address - Country:US
Practice Address - Phone:309-755-3809
Practice Address - Fax:309-755-3860
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-13
Last Update Date:2011-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016004304213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0060201286OtherBLUE CROSS AND BLUE SHIEL
IA0436154OtherIME
IA363660257003OtherTRICARE
IAP00204462OtherMEDICARE RAILROAD
IL016004304Medicaid
IL020110OtherHEALTH ALLIANCE
IA36473OtherWELLMARK BLUE CROSS BLUE SHIELD
IL326507258OtherTRICARE
IL480007485OtherMEDICARE RAILROAD
ILIL0101OtherUNITED HEALTHCARE
IAI12453OtherMEDICARE
IAIA0102OtherUNITED HEALTHCARE
IL0932570001Medicare NSC
ILIL0101OtherUNITED HEALTHCARE
IL326507258OtherTRICARE