Provider Demographics
NPI:1295721710
Name:DODGE, ROBERT THOMAS (PHD, RN, ANP)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:THOMAS
Last Name:DODGE
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Gender:M
Credentials:PHD, RN, ANP
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Mailing Address - Street 1:10 SUNNYBROOK RD
Mailing Address - Street 2:CLINIC A
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27610-1808
Mailing Address - Country:US
Mailing Address - Phone:919-250-3078
Mailing Address - Fax:919-250-4429
Practice Address - Street 1:10 SUNNYBROOK RD
Practice Address - Street 2:CLINIC A
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27610-1808
Practice Address - Country:US
Practice Address - Phone:919-250-3078
Practice Address - Fax:919-250-4429
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-20
Last Update Date:2010-06-30
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Provider Licenses
StateLicense IDTaxonomies
NC900106363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7000428Medicaid
NC7000428Medicaid
NCS86127Medicare UPIN