Provider Demographics
NPI:1255327060
Name:DODGE, RENEE L (DO)
Entity type:Individual
Prefix:DR
First Name:RENEE
Middle Name:L
Last Name:DODGE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:289 IRELAND AVE
Mailing Address - Street 2:BLDG 851 VA CLINIC
Mailing Address - City:FORT KNOX
Mailing Address - State:KY
Mailing Address - Zip Code:40121-5111
Mailing Address - Country:US
Mailing Address - Phone:502-624-0235
Mailing Address - Fax:
Practice Address - Street 1:289 IRELAND AVE
Practice Address - Street 2:BLDG 851 VA CLINIC
Practice Address - City:FORT KNOX
Practice Address - State:KY
Practice Address - Zip Code:40121-5111
Practice Address - Country:US
Practice Address - Phone:502-624-0235
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-27
Last Update Date:2012-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY02722207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64053192Medicaid
KYG93879Medicare UPIN
KY7789Medicare ID - Type Unspecified