Provider Demographics
NPI: | 1922067503 |
---|---|
Name: | HODGE, GEORGE GUSTAVE (MD) |
Entity Type: | Individual |
Prefix: | |
First Name: | GEORGE |
Middle Name: | GUSTAVE |
Last Name: | HODGE |
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 5096 |
Mailing Address - Street 2: | |
Mailing Address - City: | BELLINGHAM |
Mailing Address - State: | WA |
Mailing Address - Zip Code: | 98227-5096 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 360-733-2092 |
Mailing Address - Fax: | 360-733-4013 |
Practice Address - Street 1: | 3015 SQUALICUM PKWY |
Practice Address - Street 2: | SUITE 200 |
Practice Address - City: | BELLINGHAM |
Practice Address - State: | WA |
Practice Address - Zip Code: | 98225-1945 |
Practice Address - Country: | US |
Practice Address - Phone: | 360-733-2092 |
Practice Address - Fax: | 360-733-4013 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2006-03-21 |
Last Update Date: | 2010-09-30 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
WA | MD00011899 | 207X00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 207X00000X | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
WA | 06744 | Other | REGENCE |
WA | 4585143 | Other | AETNA |
WA | 0207954 | Other | L&I AND CRIME VICTIMS |
WA | 1922067503 | Medicaid | |
WA | 06744 | Other | REGENCE |
WA | 0207954 | Other | L&I AND CRIME VICTIMS |