Provider Demographics
NPI:1881006179
Name:HODGE, TARA ANN (MED, ATC)
Entity Type:Individual
Prefix:MS
First Name:TARA
Middle Name:ANN
Last Name:HODGE
Suffix:
Gender:F
Credentials:MED, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 ACACIA AVE
Mailing Address - Street 2:
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94901-2230
Mailing Address - Country:US
Mailing Address - Phone:415-482-1807
Mailing Address - Fax:415-482-1852
Practice Address - Street 1:1475 GRAND AVE.
Practice Address - Street 2:
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94901
Practice Address - Country:US
Practice Address - Phone:415-482-1807
Practice Address - Fax:415-482-1852
Is Sole Proprietor?:No
Enumeration Date:2014-05-21
Last Update Date:2014-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist