Provider Demographics
NPI:1740269232
Name:DODGE, LOWELL L (MD)
Entity type:Individual
Prefix:DR
First Name:LOWELL
Middle Name:L
Last Name:DODGE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26657 WOODWARD AVE
Mailing Address - Street 2:STE 200
Mailing Address - City:HUNGTINGTON WOODS
Mailing Address - State:MI
Mailing Address - Zip Code:48070
Mailing Address - Country:US
Mailing Address - Phone:248-398-8400
Mailing Address - Fax:248-398-8487
Practice Address - Street 1:26657 WOODWARD AVE
Practice Address - Street 2:STE 200
Practice Address - City:HUNGTINGTON WOODS
Practice Address - State:MI
Practice Address - Zip Code:48070
Practice Address - Country:US
Practice Address - Phone:248-398-8400
Practice Address - Fax:248-398-8487
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301032487208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1766829Medicaid
0M67730Medicare ID - Type Unspecified
MI1766829Medicaid