Provider Demographics
NPI:1457363319
Name:HODGE, RICHARD EATON
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:EATON
Last Name:HODGE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4018 N 40TH ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85018-5205
Mailing Address - Country:US
Mailing Address - Phone:602-955-0551
Mailing Address - Fax:602-956-8269
Practice Address - Street 1:4018 N 40TH ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85018-5205
Practice Address - Country:US
Practice Address - Phone:602-955-0551
Practice Address - Fax:602-956-8269
Is Sole Proprietor?:No
Enumeration Date:2006-08-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ03-716175F00000X
AZ3293207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered175F00000XOther Service ProvidersNaturopath
Not Answered207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ62967Medicare ID - Type Unspecified
AZG67714Medicare UPIN