Provider Demographics
NPI:1104973858
Name:LODGE, NANCY D (MD)
Entity type:Individual
Prefix:
First Name:NANCY
Middle Name:D
Last Name:LODGE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:NANCY
Other - Middle Name:
Other - Last Name:BARNETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:611 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FREDERICKTOWN
Mailing Address - State:MO
Mailing Address - Zip Code:63645-1111
Mailing Address - Country:US
Mailing Address - Phone:573-783-3341
Mailing Address - Fax:
Practice Address - Street 1:611 W MAIN ST
Practice Address - Street 2:
Practice Address - City:FREDERICKTOWN
Practice Address - State:MO
Practice Address - Zip Code:63645-1111
Practice Address - Country:US
Practice Address - Phone:573-783-3341
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-04
Last Update Date:2015-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ31111208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ1Z9363OtherHEALTHNET
AZ4575331OtherAETNA US HEALTHCARE
AZ164351Medicaid
AZAZ0729800OtherBLUE CROSS BLUE SHEILD