Provider Demographics
NPI:1699863332
Name:HODGE, NAN E (DPM)
Entity type:Individual
Prefix:DR
First Name:NAN
Middle Name:E
Last Name:HODGE
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:NAN
Other - Middle Name:E
Other - Last Name:HENDERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPM
Mailing Address - Street 1:500 FOOTHILL BLVD
Mailing Address - Street 2:MAIL STOP #112
Mailing Address - City:SLC
Mailing Address - State:UT
Mailing Address - Zip Code:84148-0001
Mailing Address - Country:US
Mailing Address - Phone:801-582-1565
Mailing Address - Fax:801-584-2587
Practice Address - Street 1:500 FOOTHILL BLVD
Practice Address - Street 2:MAIL STOP #112
Practice Address - City:SLC
Practice Address - State:UT
Practice Address - Zip Code:84148-0001
Practice Address - Country:US
Practice Address - Phone:801-582-1565
Practice Address - Fax:801-584-2587
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT4769118-0501213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist