Provider Demographics
NPI:1699703116
Name:HODGDON, SCOTT M (MD)
Entity type:Individual
Prefix:
First Name:SCOTT
Middle Name:M
Last Name:HODGDON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2845 GREENBRIER RD
Mailing Address - Street 2:PO BOX 8900
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54308-8900
Mailing Address - Country:US
Mailing Address - Phone:920-288-3388
Mailing Address - Fax:920-288-3370
Practice Address - Street 1:2845 GREENBRIER RD
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54311-6519
Practice Address - Country:US
Practice Address - Phone:920-288-3388
Practice Address - Fax:920-288-3370
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2008-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI26992207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30650500Medicaid
MI104514478Medicaid
MI104514487Medicaid
WIP00034402OtherRAILROAD
MI104514487Medicaid
WI30650500Medicaid