Provider Demographics
NPI:1194896902
Name:HODA, DESMOND WAYNE (DC)
Entity type:Individual
Prefix:
First Name:DESMOND
Middle Name:WAYNE
Last Name:HODA
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4308 PARK TEN DR
Mailing Address - Street 2:P.O. BOX 6188
Mailing Address - City:DIAMONDHEAD
Mailing Address - State:MS
Mailing Address - Zip Code:39525-3222
Mailing Address - Country:US
Mailing Address - Phone:228-255-5328
Mailing Address - Fax:228-255-0026
Practice Address - Street 1:4308 PARK TEN DR
Practice Address - Street 2:
Practice Address - City:DIAMONDHEAD
Practice Address - State:MS
Practice Address - Zip Code:39525-3222
Practice Address - Country:US
Practice Address - Phone:228-255-5328
Practice Address - Fax:228-255-0026
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS887111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00115761Medicaid
MS00115761Medicaid