Provider Demographics
NPI:1962515452
Name:HODGE, KEITH B (MD)
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:B
Last Name:HODGE
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:DEPT AT 952639
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:31192-2639
Mailing Address - Country:US
Mailing Address - Phone:877-485-4474
Mailing Address - Fax:
Practice Address - Street 1:7777 HENNESSY BLVD
Practice Address - Street 2:SUITE 208
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70808-4300
Practice Address - Country:US
Practice Address - Phone:225-765-8826
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2010-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA25483207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1575623Medicaid
P00235777OtherRAILROAD MEDICARE
LA1575623Medicaid
H40173Medicare UPIN
LA1575623Medicaid