Provider Demographics
NPI:1669426144
Name:LODGE, HEIDI L (MD)
Entity type:Individual
Prefix:
First Name:HEIDI
Middle Name:L
Last Name:LODGE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:HEIDI
Other - Middle Name:
Other - Last Name:LEAKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:101 COLE AVE
Mailing Address - Street 2:
Mailing Address - City:BISBEE
Mailing Address - State:AZ
Mailing Address - Zip Code:85603-1327
Mailing Address - Country:US
Mailing Address - Phone:520-432-6481
Mailing Address - Fax:520-432-5082
Practice Address - Street 1:100 E 5TH ST
Practice Address - Street 2:STE 350
Practice Address - City:DOUGLAS
Practice Address - State:AZ
Practice Address - Zip Code:85607-2859
Practice Address - Country:US
Practice Address - Phone:520-364-7659
Practice Address - Fax:520-364-8541
Is Sole Proprietor?:No
Enumeration Date:2006-05-20
Last Update Date:2022-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ22674207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ892887Medicaid
AZ892887Medicaid
AZE99400Medicare UPIN
AZ11WCFGW25Medicare ID - Type UnspecifiedMDCR GRP WCFGW