Healthcare Provider Details

I. General information

NPI: 1265458681
Provider Name (Legal Business Name): JASON MATTHEW COGDILL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/15/2006
Last Update Date: 09/12/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 EIGHTH STREET NE
CEDAR RAPIDS IA
52401-1097
US

IV. Provider business mailing address

115 EIGHTH STREET NE
CEDAR RAPIDS IA
52401-1097
US

V. Phone/Fax

Practice location:
  • Phone: 319-363-3565
  • Fax: 319-363-4001
Mailing address:
  • Phone: 319-363-3565
  • Fax: 319-363-4001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number40495
License Number StateIA
# 2
Primary TaxonomyN
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number40495
License Number StateOH

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier40495
Identifier TypeOTHER
Identifier StateIA
Identifier IssuerIOWA LICENSE NUMBER
# 2
Identifier99979
Identifier TypeOTHER
Identifier StateOH
Identifier IssuerOHIO LICENSE NUMBER

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: