Provider Demographics
NPI:1366404873
Name:DODGE, LARRY DAVID (MD)
Entity type:Individual
Prefix:DR
First Name:LARRY
Middle Name:DAVID
Last Name:DODGE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:4060 4TH AVE
Mailing Address - Street 2:SUITE 700
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-2116
Mailing Address - Country:US
Mailing Address - Phone:609-299-8500
Mailing Address - Fax:619-297-1443
Practice Address - Street 1:4060 4TH AVE
Practice Address - Street 2:SUITE 700
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-2116
Practice Address - Country:US
Practice Address - Phone:609-299-8500
Practice Address - Fax:619-297-1443
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG46528207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G465280Medicaid
A50413Medicare UPIN
CAWG46528BMedicare ID - Type Unspecified