1639114663 NPI number — RICHARD LORNAL DODGE PHD CADCII ICRE

Table of content: RICHARD LORNAL DODGE PHD CADCII ICRE (NPI 1639114663)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639114663 NPI number — RICHARD LORNAL DODGE PHD CADCII ICRE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DODGE
Provider First Name:
RICHARD
Provider Middle Name:
LORNAL
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PHD CADCII ICRE
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
DODGE
Provider Other First Name:
DICK
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PHD
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1639114663
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/18/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3407 SHAMPROCK CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GAUTIER
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39553
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
228-497-0690
Provider Business Mailing Address Fax Number:
228-497-1363

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3407 SHAMROCK CT
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GAUTIER
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39553
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
228-497-0690
Provider Business Practice Location Address Fax Number:
228-497-1363
Provider Enumeration Date:
06/16/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YA0400X , with the licence number:  A8424202 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 00018214 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".




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