Provider Demographics
NPI:1790108405
Name:HODGE, DEBORAH
Entity Type:Individual
Prefix:
First Name:DEBORAH
Middle Name:
Last Name:HODGE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4001 KALUGA PARK ST
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32808-7473
Mailing Address - Country:US
Mailing Address - Phone:407-982-6629
Mailing Address - Fax:
Practice Address - Street 1:4001 KALUGA PARK ST
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32808-7473
Practice Address - Country:US
Practice Address - Phone:407-982-6629
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-31
Last Update Date:2014-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL7G331A/C171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL684197096OtherMEDWAIVER
FL684197098OtherMEDWAIVER
FL6841970001OtherMEDWAIVER