Healthcare Provider Details

I. General information

NPI: 1801849138
Provider Name (Legal Business Name): NANCY N DODGE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/18/2006
Last Update Date: 10/07/2022
Certification Date: 10/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

35 MICHIGAN ST NE SUITE 3003
GRAND RAPIDS MI
49503-2514
US

IV. Provider business mailing address

100 MICHIGAN ST NE MC 845
GRAND RAPIDS MI
49503-2560
US

V. Phone/Fax

Practice location:
  • Phone: 616-267-2009
  • Fax: 616-267-2010
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080P0006X
TaxonomyDevelopmental - Behavioral Pediatrics Physician
License Number4301087152
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code2080P0008X
TaxonomyPediatric Neurodevelopmental Disabilities Physician
License Number4301087152
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: