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General NPI Number Information
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NPI Number | 1669426144
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Entity Type | Individual
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Provider Name | HEIDI L LODGE MD
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Gender | Female
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Dates
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Enumeration Date | 05/20/2006
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Last Update Date | 08/12/2022
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Provider Practice Location Address
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Address Line | 100 E 5TH ST STE 350
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City | DOUGLAS
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State | AZ
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Zip | 85607-2859
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Country | US
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Telephone | 520-364-7659
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Fax | 520-364-8541
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Provider Business Mailing Address
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Address Line | 101 COLE AVE
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City | BISBEE
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State | AZ
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Zip | 85603-1327
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Country | US
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Telephone | 520-432-6481
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Fax | 520-432-5082
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | 22674
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License Number State | AZ
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