Individual
NANCY D LODGE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
MD
Contact information
Practice address
611 W MAIN ST, FREDERICKTOWN, MO 63645-1111
(573) 783-3341
Mailing address
611 W MAIN ST, FREDERICKTOWN, MO 63645-1111
(573) 783-3341
Taxonomy
Speciality
Code
Description
License number
State
208000000X
Pediatrics Physician
Primary
31111
AZ
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
164351
—
AZ
01
—
1Z9363
HEALTHNET
AZ
01
—
4575331
AETNA US HEALTHCARE
AZ
01
—
AZ0729800
BLUE CROSS BLUE SHEILD
AZ
Enumeration date
01/04/2007
Last updated
06/05/2015
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