Basic Information
| Provider Information | |||||||||
| NPI: | 1801872916 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HODER | ||||||||
| FirstName: | EDWARD | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 147 MILK ST | ||||||||
| Address2: | 9TH FLOOR - HARVARD VANGARD MEDICAL ASSOCIATES | ||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021094806 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6175598239 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 20 WALL ST | ||||||||
| Address2: | HARVARD VANGARD MEDICAL ASSOCIATES | ||||||||
| City: | BURLINGTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 018034758 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7812212800 | ||||||||
| FaxNumber: | 7812212680 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/20/2005 | ||||||||
| LastUpdateDate: | 06/07/2012 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 60217 | MA | Y | Allopathic & Osteopathic Physicians | Pediatrics | 2080N0001X | 60217 | MA | N | Allopathic & Osteopathic Physicians | Pediatrics | Neonatal-Perinatal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0873965 | 01 | MA | CIGNA | OTHER | 12-04572 | 01 | MA | UNITED HEALTHCARE | OTHER | 722650 | 01 | MA | TUFTS | OTHER | J07891 | 01 | MA | BLUE CROSS | OTHER | 3547313 | 01 | MA | AETNA | OTHER | 0003778 | 01 | MA | NEIGHBORHOOD HEALTH | OTHER | AA8202 | 01 | MA | HARVARD PILGRIM | OTHER | 3040020 | 05 | MA | MEDICAID |