Provider Demographics
NPI:1790861987
Name:HODEL, SANDRA J (MD)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:J
Last Name:HODEL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SANDRA
Other - Middle Name:
Other - Last Name:FULLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2900 FRANK SCOTT PKWY W
Mailing Address - Street 2:950
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62223-5000
Mailing Address - Country:US
Mailing Address - Phone:618-233-3205
Mailing Address - Fax:618-233-1407
Practice Address - Street 1:2900 FRANK SCOTT PKWY W
Practice Address - Street 2:950
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62223-5000
Practice Address - Country:US
Practice Address - Phone:618-233-3205
Practice Address - Fax:618-233-1407
Is Sole Proprietor?:No
Enumeration Date:2006-10-31
Last Update Date:2014-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036118953208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
F29796Medicare UPIN
ILK46394Medicare PIN