Healthcare Provider Details

I. General information

NPI: 1255327060
Provider Name (Legal Business Name): RENEE L DODGE D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/27/2005
Last Update Date: 11/07/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

289 IRELAND AVE BLDG 851 VA CLINIC
FORT KNOX KY
40121-5111
US

IV. Provider business mailing address

289 IRELAND AVE BLDG 851 VA CLINIC
FORT KNOX KY
40121-5111
US

V. Phone/Fax

Practice location:
  • Phone: 502-624-0235
  • Fax:
Mailing address:
  • Phone: 502-624-0235
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberKY02722
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: