Healthcare Provider Details

I. General information

NPI: 1225027253
Provider Name (Legal Business Name): TIMOTHY P HODGES DO. FAMILY PRACTICE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/21/2005
Last Update Date: 12/28/2023
Certification Date: 12/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6052 W STATE ST
BOISE ID
83703-2739
US

IV. Provider business mailing address

PO BOX 191050
BOISE ID
83719-1050
US

V. Phone/Fax

Practice location:
  • Phone: 208-955-6500
  • Fax: 208-955-6501
Mailing address:
  • Phone: 208-955-6500
  • Fax: 208-955-6501

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0109
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: