Provider Demographics
NPI:1356365233
Name:HODGES, CLARETTA (MD)
Entity type:Individual
Prefix:
First Name:CLARETTA
Middle Name:
Last Name:HODGES
Suffix:
Gender:F
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 388320
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60638-8320
Mailing Address - Country:US
Mailing Address - Phone:773-767-4600
Mailing Address - Fax:773-767-8320
Practice Address - Street 1:45 W 111TH ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60628-4200
Practice Address - Country:US
Practice Address - Phone:773-995-3057
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2009-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036045093207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL01622034OtherBLUE SHIELD
050076615OtherRAILROAD MEDICARE
IL036045093Medicaid
C38471Medicare UPIN
IL205335Medicare ID - Type Unspecified