MEDICARE: MR. DOUGLAS BRYANT HODGE CO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	222Z00000X	Orthotist	CO001774	DE

General Provider Information

NPI Number	:	1174020317
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. DOUGLAS BRYANT HODGE CO

Provider Business Mailing Address
First Line	:	9591 VALPARAISO CT
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46268-1130
Country	:	US
Telephone Number	:	317-218-4270
Fax Number	:	317-218-4271

Provider Business Practice Location Address
First Line	:	9591 VALPARAISO CT
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46268-1130
Country	:	US
Telephone Number	:	317-218-4270
Fax Number	:	317-218-4271

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/12/2018
Last Update Date	:	04/12/2018

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