1750818175 NPI number — JEFFREY R HODGSON MD CORPORATION

Table of content: (NPI 1750818175)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750818175 NPI number — JEFFREY R HODGSON MD CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JEFFREY R HODGSON MD CORPORATION
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1750818175
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/05/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2131
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
APTOS
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95001-2131
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
312-305-9378
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
20100 QUARTZ MOUNTAIN RD
Provider Second Line Business Practice Location Address:
N
Provider Business Practice Location Address City Name:
FIDDLETOWN
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95629
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
209-206-1177
Provider Business Practice Location Address Fax Number:
209-206-1177
Provider Enumeration Date:
05/16/2017

Additional Information

Authorized Official

Authorized Official Last Name:
HODGSON
Authorized Official First Name:
JEFFREY
Authorized Official Middle Name:
ROSS
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
312-305-9378

Provider Taxonomy Codes

  • Taxonomy code: 207LP2900X , with the licence number:  A100211 , 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: 1629278494 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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