Provider Demographics
NPI:1700856432
Name:HODGES, LEROY W (MD)
Entity Type:Individual
Prefix:
First Name:LEROY
Middle Name:W
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 1:1220 CHATBURN AVE
Mailing Address - Street 2:
Mailing Address - City:HARLAN
Mailing Address - State:IA
Mailing Address - Zip Code:51537-2009
Mailing Address - Country:US
Mailing Address - Phone:712-755-4376
Mailing Address - Fax:712-755-4347
Practice Address - Street 1:1220 CHATBURN AVE
Practice Address - Street 2:
Practice Address - City:HARLAN
Practice Address - State:IA
Practice Address - Zip Code:51537-2009
Practice Address - Country:US
Practice Address - Phone:712-755-4376
Practice Address - Fax:712-755-4347
Is Sole Proprietor?:No
Enumeration Date:2006-01-25
Last Update Date:2023-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN66366208600000X
IAMD-50086208600000X
MN30115208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN961423100Medicaid
MN961423100Medicaid
MNE69119Medicare UPIN
MN020001637Medicare ID - Type Unspecified