Provider Demographics
NPI:1487753505
Name:HODGES, LORALIE ELLINGTON (OD)
Entity type:Individual
Prefix:
First Name:LORALIE
Middle Name:ELLINGTON
Last Name:HODGES
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:LORALIE
Other - Middle Name:
Other - Last Name:ELLINGTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:331 SIJEN AVE
Mailing Address - Street 2:
Mailing Address - City:WHITEMAN AFB
Mailing Address - State:MO
Mailing Address - Zip Code:65305-1269
Mailing Address - Country:US
Mailing Address - Phone:660-687-3937
Mailing Address - Fax:
Practice Address - Street 1:331 SIJEN AVE
Practice Address - Street 2:
Practice Address - City:WHITEMAN AFB
Practice Address - State:MO
Practice Address - Zip Code:65305-1269
Practice Address - Country:US
Practice Address - Phone:660-687-3937
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2021-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1739152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS651140OtherBCBS
KS20410560AMedicaid