Healthcare Provider Details

I. General information

NPI: 1730734880
Provider Name (Legal Business Name): MANDY KORINE HODGES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/06/2019
Last Update Date: 08/06/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

509 E HIGHWAY 33
PERKINS OK
74059-4129
US

IV. Provider business mailing address

509 E HIGHWAY 33
PERKINS OK
74059-4129
US

V. Phone/Fax

Practice location:
  • Phone: 405-547-2473
  • Fax: 405-547-2925
Mailing address:
  • Phone: 405-547-2473
  • Fax: 405-547-2925

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: