Basic Information
Provider Information | |||||||||
NPI: | 1619905429 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DODGE | ||||||||
FirstName: | JAMES | ||||||||
MiddleName: | THEODORE | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: | JR. | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | DODGE | ||||||||
OtherFirstName: | J | ||||||||
OtherMiddleName: | THEODORE | ||||||||
OtherNamePrefix: | DR. | ||||||||
OtherNameSuffix: | JR. | ||||||||
OtherCredential: | MD | ||||||||
OtherLastNameType: | 2 | ||||||||
Mailing Information | |||||||||
Address1: | 820 N CHELAN AVE | ||||||||
Address2: |   | ||||||||
City: | WENATCHEE | ||||||||
State: | WA | ||||||||
PostalCode: | 988012028 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5096638711 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1201 S MILLER ST STE A | ||||||||
Address2: |   | ||||||||
City: | WENATCHEE | ||||||||
State: | WA | ||||||||
PostalCode: | 988013201 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5096638711 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/29/2006 | ||||||||
LastUpdateDate: | 07/14/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RI0011X | MD00031058 | WA | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology |
ID Information
ID | Type | State | Issuer | Description | 315914 | 01 | WA | WVH LNI | OTHER | P01256388 | 01 | WA | RR MEDICARE WVH | OTHER | 1619905429 | 05 | WA |   | MEDICAID |