Provider Demographics
NPI:1639675937
Name:HODGES, DAVITA MABOURAKH (MD)
Entity type:Individual
Prefix:
First Name:DAVITA
Middle Name:MABOURAKH
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 1:6451 W COMMERCIAL BLVD
Mailing Address - Street 2:
Mailing Address - City:TAMARAC
Mailing Address - State:FL
Mailing Address - Zip Code:33319-2110
Mailing Address - Country:US
Mailing Address - Phone:549-720-1414
Mailing Address - Fax:954-720-4727
Practice Address - Street 1:6451 W COMMERCIAL BLVD
Practice Address - Street 2:
Practice Address - City:TAMARAC
Practice Address - State:FL
Practice Address - Zip Code:33319-2110
Practice Address - Country:US
Practice Address - Phone:549-720-1414
Practice Address - Fax:954-720-4727
Is Sole Proprietor?:No
Enumeration Date:2018-04-04
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA11140800207R00000X
NCRTL22-0632207RG0300X
390200000X
FLME153182207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program