Healthcare Provider Details

I. General information

NPI: 1174020317
Provider Name (Legal Business Name): DOUGLAS BRYANT HODGE CO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/12/2018
Last Update Date: 04/12/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9591 VALPARAISO CT
INDIANAPOLIS IN
46268-1130
US

IV. Provider business mailing address

9591 VALPARAISO CT
INDIANAPOLIS IN
46268-1130
US

V. Phone/Fax

Practice location:
  • Phone: 317-218-4270
  • Fax: 317-218-4271
Mailing address:
  • Phone: 317-218-4270
  • Fax: 317-218-4271

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code222Z00000X
TaxonomyOrthotist
License NumberCO001774
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: