Provider Demographics
NPI:1548498975
Name:HODGE, SHANE MICHAEL (DO)
Entity type:Individual
Prefix:DR
First Name:SHANE
Middle Name:MICHAEL
Last Name:HODGE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 986
Mailing Address - Street 2:
Mailing Address - City:OXFORD
Mailing Address - State:NC
Mailing Address - Zip Code:27565-0986
Mailing Address - Country:US
Mailing Address - Phone:919-690-3487
Mailing Address - Fax:919-690-3246
Practice Address - Street 1:102 PROFESSIONAL PARK STE C
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:NC
Practice Address - Zip Code:27565-2554
Practice Address - Country:US
Practice Address - Phone:919-603-0368
Practice Address - Fax:919-690-0842
Is Sole Proprietor?:No
Enumeration Date:2009-06-24
Last Update Date:2023-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2011-00897208600000X
MI5101016839208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCNC2803AOtherMEDICARE PTAN, INDIVIDUAL
NC5918846Medicaid
NC2335816OtherMEDICARE PTAN, GROUP