Provider Demographics
NPI:1790770428
Name:LODGE, FREDERICK A (MD)
Entity Type:Individual
Prefix:DR
First Name:FREDERICK
Middle Name:A
Last Name:LODGE
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:PO BOX 492680
Mailing Address - Street 2:
Mailing Address - City:REDDING
Mailing Address - State:CA
Mailing Address - Zip Code:96049-2680
Mailing Address - Country:US
Mailing Address - Phone:530-243-0440
Mailing Address - Fax:530-243-0445
Practice Address - Street 1:580 N SPRING ST
Practice Address - Street 2:
Practice Address - City:UKIAH
Practice Address - State:CA
Practice Address - Zip Code:95482-4251
Practice Address - Country:US
Practice Address - Phone:707-468-5015
Practice Address - Fax:707-468-5015
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-19
Last Update Date:2010-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG57207174400000X
CA00G572072207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAYYY20507YMedicaid
CAA53249Medicare UPIN
CAYYY20507YMedicaid