Basic Information
| Provider Information | |||||||||
| NPI: | 1790861987 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HODEL | ||||||||
| FirstName: | SANDRA | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | |||||||||
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| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | FULLER | ||||||||
| OtherFirstName: | SANDRA | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2900 FRANK SCOTT PKWY W | ||||||||
| Address2: | 950 | ||||||||
| City: | BELLEVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622235000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6182333205 | ||||||||
| FaxNumber: | 6182331407 | ||||||||
| Practice Location | |||||||||
| Address1: | 2900 FRANK SCOTT PKWY W | ||||||||
| Address2: | 950 | ||||||||
| City: | BELLEVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622235000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6182333205 | ||||||||
| FaxNumber: | 6182331407 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/31/2006 | ||||||||
| LastUpdateDate: | 01/14/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 036118953 | IL | Y | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.