Provider Demographics
NPI:1679534226
Name:DODGE, NICHOLAS DAVID (MD)
Entity type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:DAVID
Last Name:DODGE
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:121 VOSBURG LN
Mailing Address - Street 2:
Mailing Address - City:CLARKS SUMMIT
Mailing Address - State:PA
Mailing Address - Zip Code:18411-2717
Mailing Address - Country:US
Mailing Address - Phone:570-344-5115
Mailing Address - Fax:570-344-2123
Practice Address - Street 1:414 E DRINKER ST STE 204
Practice Address - Street 2:
Practice Address - City:DUNMORE
Practice Address - State:PA
Practice Address - Zip Code:18512-2469
Practice Address - Country:US
Practice Address - Phone:570-344-5115
Practice Address - Fax:570-344-2123
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-31
Last Update Date:2023-12-06
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
PAMD054271L207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA002981OtherFIRST PRIORITY HMO
PA616633OtherBLUE SHIELD PA
PA001508646Medicaid
PA616633OtherFPLIC
PAP00025321OtherRAILROAD MEDICARE
1679534226OtherNPI
PA002981OtherFIRST PRIORITY HMO