Provider Demographics
NPI:1750818175
Name:JEFFREY R HODGSON MD CORPORATION
Entity type:Organization
Organization Name:JEFFREY R HODGSON MD CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:ROSS
Authorized Official - Last Name:HODGSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:312-305-9378
Mailing Address - Street 1:PO BOX 2131
Mailing Address - Street 2:
Mailing Address - City:APTOS
Mailing Address - State:CA
Mailing Address - Zip Code:95001-2131
Mailing Address - Country:US
Mailing Address - Phone:312-305-9378
Mailing Address - Fax:
Practice Address - Street 1:20100 QUARTZ MOUNTAIN RD
Practice Address - Street 2:N
Practice Address - City:FIDDLETOWN
Practice Address - State:CA
Practice Address - Zip Code:95629
Practice Address - Country:US
Practice Address - Phone:209-206-1177
Practice Address - Fax:209-206-1177
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-16
Last Update Date:2024-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA100211207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1629278494Medicaid