=====================================================
General NPI Number Information
=====================================================
NPI Number | 1447692553
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MRS. OLIVIA HODGE
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/18/2013
-----------------------------------------------------
Last Update Date | 10/05/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 678MACON STREET
-----------------------------------------------------
City | UNIONDALE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11553-2414
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-555-1212
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 678 MACON PL
-----------------------------------------------------
City | UNIONDALE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11553-2924
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-555-1212
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 74227071
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------