Healthcare Provider Details

I. General information

NPI: 1114993482
Provider Name (Legal Business Name): JEFFREY ALAN DODGE DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/27/2006
Last Update Date: 10/08/2024
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

46 BROAD STREET, SUITE A
PLATTSBURGH NY
12901-3301
US

IV. Provider business mailing address

46 BROAD STREET, SUITE A,
PLATTSBURGH NY
12901-3301
US

V. Phone/Fax

Practice location:
  • Phone: 518-566-9452
  • Fax: 518-566-9831
Mailing address:
  • Phone: 518-566-9452
  • Fax: 518-562-7189

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number219394
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: