=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114993482
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JEFFREY ALAN DODGE DO
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/27/2006
-----------------------------------------------------
Last Update Date | 10/08/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 46 BROAD STREET, SUITE A
-----------------------------------------------------
City | PLATTSBURGH
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12901-3301
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 518-566-9452
-----------------------------------------------------
Fax | 518-566-9831
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 46 BROAD STREET, SUITE A,
-----------------------------------------------------
City | PLATTSBURGH
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12901-3301
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 518-566-9452
-----------------------------------------------------
Fax | 518-562-7189
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207V00000X
-----------------------------------------------------
Taxonomy Name | Obstetrics & Gynecology Physician
-----------------------------------------------------
License Number | 219394
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------