Provider Demographics
NPI:1699966358
Name:JEFFREY DODD MD A PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:JEFFREY DODD MD A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:
Authorized Official - Last Name:SMALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:530-587-7461
Mailing Address - Street 1:10051 LAKE AVE
Mailing Address - Street 2:SUITE 3
Mailing Address - City:TRUCKEE
Mailing Address - State:CA
Mailing Address - Zip Code:96161-4825
Mailing Address - Country:US
Mailing Address - Phone:530-587-7461
Mailing Address - Fax:530-587-1149
Practice Address - Street 1:10051 LAKE AVE
Practice Address - Street 2:SUITE 3
Practice Address - City:TRUCKEE
Practice Address - State:CA
Practice Address - Zip Code:96161-4825
Practice Address - Country:US
Practice Address - Phone:530-587-7461
Practice Address - Fax:530-587-1149
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-07
Last Update Date:2009-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA81163174400000X, 332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A811630Medicaid
1699966358OtherBLUE CROSS
P00089905OtherRAILROAD MEDICARE
1699966358OtherBLUE CROSS
5245670001Medicare NSC
CA00A811630Medicaid