Provider Demographics
NPI:1134197833
Name:HODEL, KENNTH ALAN (MD)
Entity type:Individual
Prefix:
First Name:KENNTH
Middle Name:ALAN
Last Name:HODEL
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 1:6915 N KNOXVILLE AVE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614
Mailing Address - Country:US
Mailing Address - Phone:309-683-8910
Mailing Address - Fax:309-683-8911
Practice Address - Street 1:6915 N KNOXVILLE AVE
Practice Address - Street 2:SUITE 1
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-2851
Practice Address - Country:US
Practice Address - Phone:309-683-8910
Practice Address - Fax:309-683-8911
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207VX0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VX0201XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologic Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILA24511Medicaid
593520Medicare ID - Type Unspecified
A24511Medicare UPIN
ILA24511Medicaid