Healthcare Provider Details

I. General information

NPI: 1669426144
Provider Name (Legal Business Name): HEIDI L LODGE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: HEIDI LEAKE

II. Dates (important events)

Enumeration Date: 05/20/2006
Last Update Date: 08/12/2022
Certification Date: 09/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 E 5TH ST STE 350
DOUGLAS AZ
85607-2859
US

IV. Provider business mailing address

101 COLE AVE
BISBEE AZ
85603-1327
US

V. Phone/Fax

Practice location:
  • Phone: 520-364-7659
  • Fax: 520-364-8541
Mailing address:
  • Phone: 520-432-6481
  • Fax: 520-432-5082

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number22674
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: