Provider Demographics
NPI:1922311851
Name:LODGE, JUSTIN ROBERT (DPT)
Entity Type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:ROBERT
Last Name:LODGE
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:625 ENTERPRISE DR
Mailing Address - Street 2:
Mailing Address - City:OAK BROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60523-8813
Mailing Address - Country:US
Mailing Address - Phone:630-575-6200
Mailing Address - Fax:
Practice Address - Street 1:8805 N MAIN ST
Practice Address - Street 2:STE 110
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45415-1333
Practice Address - Country:US
Practice Address - Phone:937-204-1877
Practice Address - Fax:937-204-1878
Is Sole Proprietor?:No
Enumeration Date:2010-07-20
Last Update Date:2017-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL256672251X0800X
OH0143552251X0800X
OHPT014355225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic